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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Providing the patient with photos of the fetus can be a part of memory-making and is often a key component of care after a stillbirth. It allows parents to remember their baby and can aid in the grieving process.
Choice B rationale
While an autopsy can provide information about why a stillbirth occurred, it is not mandatory and should be discussed with the parents. The decision to perform an autopsy should be based on the parents’ wishes.
Choice C rationale
Limiting the amount of time the fetus is in the patient’s room is not necessarily beneficial. Some parents may want to spend time with their baby to say goodbye, which can be therapeutic.
Choice D rationale
Informing the patient that the law requires them to name the fetus is not accurate. The decision to name the fetus is a personal one and varies among individuals.
Correct Answer is B
Explanation
Choice A rationale
Frequent urination is a common symptom in early pregnancy due to the increased blood flow to the woman’s kidneys. This is a normal physiological change and does not require immediate attention.
Choice B rationale
Severe vomiting at 8 weeks of gestation could indicate hyperemesis gravidarum, a severe form of nausea and vomiting in pregnancy that can lead to dehydration and weight loss. This
condition requires immediate medical attention as it can have serious health implications for both the mother and the baby.
Choice C rationale
Back pain following intercourse at 36 weeks of gestation could be a sign of labor. However, it is not as urgent as severe vomiting in early pregnancy which can lead to dehydration.
Choice D rationale
Periodic tingling of the fingers at 24 weeks of gestation could be due to physiological changes in pregnancy such as fluid retention causing carpal tunnel syndrome. While this can be uncomfortable, it is not a medical emergency.
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