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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Massaging the client's fundus is not indicated for hypotension following epidural anesthesia.
Fundal massage is typically performed to prevent or manage uterine atony and postpartum hemorrhage.
B. Turning the client to a side-lying position is a recommended intervention for hypotension following epidural anesthesia. This position helps improve venous return to the heart and can help alleviate hypotension by reducing aortocaval compression.
C. Applying oxygen via nasal cannula may be indicated if the client is experiencing respiratory distress, but it is not the primary intervention for hypotension.
D. Assisting the client to empty their bladder may be appropriate to relieve urinary retention but is not the priority intervention for hypotension.
Correct Answer is A
Explanation
A.
Rationale:
A. Maternal cytomegalovirus can be transmitted to the newborn through contact with infected bodily fluids, including saliva and urine.
B. Airborne precautions are not necessary for cytomegalovirus, as it is primarily transmitted through contact with infected bodily fluids, not through airborne droplets.
C. There is no prophylactic treatment with acyclovir for cytomegalovirus; treatment options are limited and typically reserved for severe cases.
D. Lesions are not typically visible on the mother's genitalia with cytomegalovirus; the virus is often asymptomatic or causes mild symptoms in healthy adults.
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