A nurse is assessing a client who is 3 days postpartum. Which of the following findings should the nurse report to the provider?
BP 120/70 mm Hg
Cool clammy skin
Moderate lochia serosa
Heart rate 89/min
The Correct Answer is B
Rationale:
A. A blood pressure of 120/70 mm Hg is within the normal range for a postpartum client and does not require immediate reporting to the provider.
B. Cool clammy skin may indicate hypoperfusion or inadequate blood flow, which could be a sign of hemorrhage or other circulatory issues. This finding should be reported promptly for further evaluation and intervention.
C. Moderate lochia serosa is a normal finding in the early postpartum period and does not typically require immediate reporting.
D. A heart rate of 89/min is within the normal range for a postpartum client and does not require immediate reporting to the provider.
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Related Questions
Correct Answer is A
Explanation
A.
Rationale:
A. The McRoberts maneuver involves flexing the mother's thighs onto her abdomen to straighten the pelvis and allow for easier passage of the baby's shoulder. This action helps to widen the pelvic outlet and facilitate delivery.
B. Applying pressure to the client's fundus is not part of the McRoberts maneuver. Fundal pressure may be used in other techniques to manage shoulder dystocia, such as the Rubin maneuver or Woods' screw maneuver.
C. Pressing firmly on the client's suprapubic area is not part of the McRoberts maneuver. This action may be performed in conjunction with other maneuvers to help dislodge the impacted shoulder.
D. Moving the client onto their hands and knees is not part of the McRoberts maneuver. This position, known as the Gaskin maneuver, may be used as an alternative maneuver to alleviate shoulder dystocia by changing the orientation of the pelvis.
Correct Answer is C
Explanation
Rationale:
A. An apneic episode less than 15 seconds may be considered within normal limits for a newborn and does not necessarily indicate a decline in status.
B. Fine crackles may indicate fluid in the lungs but are not specific to a decline in the newborn's status.
C. An oxygen saturation of 89% indicates hypoxemia, which is a significant concern and suggests respiratory compromise. It indicates a decline in the newborn's status and requires immediate intervention to improve oxygenation.
D. Nasal flaring is a sign of respiratory distress but may not be as concerning as a low oxygen saturation level in this context. It indicates increased work of breathing but does not provide direct information about oxygenation status.
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