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 D
Explanation
A: Administering an IV bolus of lactated Ringer's is typically used to correct electrolyte imbalances or as a volume expander in the case of blood loss. In peripartum cardiomyopathy, fluid overload should be avoided as it can exacerbate heart failure symptoms.
B: Misoprostol is used to prevent or treat postpartum hemorrhage, but it is not directly related to the management of peripartum cardiomyopathy.
C. Assess blood pressure twice daily:
While monitoring blood pressure is important for overall cardiovascular management, assessing it only twice daily is insufficient for a client with peripartum cardiomyopathy. This condition requires frequent and comprehensive monitoring of vital signs, fluid balance, and cardiac function to prevent complications.
D. Restrict daily oral fluid intake:
Restricting fluid intake is a key intervention in managing peripartum cardiomyopathy because it helps to prevent fluid overload, which could exacerbate heart failure. Clients with this condition often experience reduced cardiac output, and limiting fluids can reduce the strain on the heart and improve overall management of symptoms
Correct Answer is D
Explanation
Rationale:
A. A temperature of 37.4°C (99.3°F) may be within the normal range, but it can also indicate a fever, which is common with endometritis.
B. A WBC count of 9,000/mm3 is within the normal range, but it may be elevated in response to infection such as endometritis.
C. Scant lochia is not typically associated with endometritis; instead, clients with endometritis may have increased or foul-smelling lochia.
D. Uterine tenderness is a common finding in clients with endometritis, as the infection causes inflammation and discomfort in the uterine lining.
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