A nurse is assessing a client who is 3 days postpartum.
Which of the following findings should the nurse report to the provider?
Heart rate 89/min.
BP 120/70 mm Hg.
Moderate lochia serosa.
Cool, clammy skin.
The Correct Answer is D
Choice A rationale
A heart rate of 89/min is within the normal range for adults, and would not typically be a cause for concern.
Choice B rationale
A blood pressure of 120/70 mm Hg is considered normal for adults.
Choice C rationale
Moderate lochia serosa is a normal part of the postpartum period.
Choice D rationale
This is the correct answer. Cool, clammy skin can be a sign of postpartum hemorrhage, a serious condition that requires immediate medical attention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Applying firm pressure on the client’s suprapubic area is not part of the McRoberts maneuver. This action is more associated with the suprapubic pressure technique, which is another method used to manage shoulder dystocia.
Choice B rationale
The McRoberts maneuver involves having the client flex her hips against her abdomen. This is achieved by assisting the client in pulling her knees toward her abdomen.
Choice C rationale
Applying pressure to the client’s fundus is not part of the McRoberts maneuver and can be contraindicated as it may cause additional complications.
Choice D rationale
Moving the client onto their hands and knees is not part of the McRoberts maneuver. This position is more associated with the all-fours maneuver, also known as the Gaskin maneuver.
Correct Answer is D
Explanation
The correct answer is choice d. Transmission can occur via the saliva and urine of the newborn.
Choice A rationale:
Lesions are not typically visible on the mother’s genitalia with cytomegalovirus (CMV) infection. CMV is often asymptomatic or presents with nonspecific symptoms, and visible lesions are not a characteristic feature.
Choice B rationale:
CMV does not require airborne precautions. It is primarily transmitted through direct contact with bodily fluids such as saliva, urine, blood, and breast milk.
Choice C rationale:
Prophylactic treatment with acyclovir is not standard for CMV. Acyclovir is used for herpes simplex virus infections, not CMV.
Choice D rationale:
CMV can indeed be transmitted via the saliva and urine of the newborn. This is a common mode of transmission, especially in settings like daycare centers where young children are in close contact.
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