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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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Massaging the client’s fundus is not indicated in this situation. Fundal massage is typically done after childbirth to help the uterus contract and prevent excessive bleeding.
Choice B rationale
Applying oxygen can help increase the client’s oxygen saturation levels, but it does not directly address the cause of the hypotension.
Choice C rationale
Turning the client to a side-lying position, specifically the left lateral position, can help improve blood flow to the heart, increasing cardiac output and blood pressure.
Choice D rationale
Assisting the client to empty their bladder is important in postpartum care, but it is not the immediate action to take when a client is hypotensive following the administration of epidural anesthesia.
Correct Answer is A
Explanation
Choice A rationale
It is crucial to confirm that informed consent has been obtained before administering a dinoprostone insert to induce labor. This is because the patient has the right to understand the benefits, risks, and alternatives of the procedure before it is performed.
Choice B rationale
Positioning the client in a semi-Fowler’s position for 1 hour after administration is not necessary. After the dinoprostone insert is placed, the patient should remain lying down for at least 30 minutes. After this, the patient may sit up or walk, being careful to ensure the insert remains in place.
Choice C rationale
Allowing the medication to reach room temperature before administration is not a requirement for dinoprostone insert. The medication can be administered as soon as it is needed.
Choice D rationale
Advising the client to avoid urinating until after administration is not necessary. The patient can urinate as needed after the dinoprostone insert is placed.
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