A nurse is assessing a client who is 6 hr following a vaginal birth and experienced a placental abruption. Which of the following findings should the nurse report to the provider?
Moderate lochia rubra on the perineal pad
1+ nonpitting ankle edema
Urine output 400 mL within two voids
Petechiae on the skin under the blood pressure cuff
The Correct Answer is D
Choice A reason: Moderate lochia rubra is expected within the first 24 hours postpartum. Lochia rubra consists of blood and decidual tissue and should be moderate in amount. This finding is normal and does not indicate a complication. It would only be concerning if the lochia were excessive, foul-smelling, or accompanied by large clots, which could suggest postpartum hemorrhage or infection.
Choice B reason: 1+ nonpitting ankle edema is a common finding in the immediate postpartum period due to fluid shifts and increased vascular volume during pregnancy. Mild edema is not unusual and typically resolves as diuresis occurs in the days following delivery. This finding does not require immediate provider notification unless it progresses to severe edema or is associated with hypertension, which could indicate preeclampsia.
Choice C reason: A urine output of 400 mL within two voids is within normal limits. Postpartum women often experience diuresis as the body eliminates excess fluid retained during pregnancy. Adequate urine output indicates good renal perfusion and hydration status. Oliguria (less than 30 mL/hr) would be concerning, but this finding does not meet that threshold.
Choice D reason: Petechiae under the blood pressure cuff are abnormal and concerning. Petechiae suggest capillary fragility or a coagulation disorder, which may occur in the context of disseminated intravascular coagulation (DIC). Placental abruption is a known risk factor for DIC because of the release of thromboplastin into maternal circulation, which can trigger widespread clotting and subsequent bleeding. This finding requires immediate provider notification because it may indicate a life-threatening complication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Massaging the area of a pressure ulcer is contraindicated. Massage can damage fragile capillaries and tissues, worsening the ulcer and increasing the risk of further breakdown. It may also cause pain and inflammation. Therefore, this intervention is inappropriate for a stage II ulcer.
Choice B reason: An alternating pressure mattress is an evidence-based intervention that helps redistribute pressure across the body and reduces the risk of further skin breakdown. For a comatose client who cannot reposition themselves, this intervention is especially important. It promotes circulation and prevents worsening of the ulcer, making it the most appropriate choice.
Choice C reason: A sterile, dry gauze dressing is not the recommended treatment for a stage II ulcer. Stage II ulcers involve partial-thickness skin loss and require a moist wound environment to promote healing. Dry gauze can adhere to the wound bed, cause trauma during removal, and delay healing. Moist dressings such as hydrocolloids or foam dressings are preferred.
Choice D reason: Donut-shaped cushions are not recommended because they concentrate pressure around the wound edges, worsening ischemia and tissue damage. They can increase the risk of ulcer progression rather than prevent it. This intervention is inappropriate for pressure ulcer management.
Correct Answer is A
Explanation
Choice A reason: Telling the client “I don’t hear the voices. Concentrate on my voice instead” is therapeutic because it acknowledges the client’s experience without reinforcing the hallucination. It helps the client refocus on reality and provides grounding, which is an effective strategy in managing hallucinations. This is the correct answer.
Choice B reason: Saying “They cannot hurt you” invalidates the client’s perception and may increase anxiety. While intended to reassure, it does not help the client differentiate between hallucinations and reality.
Choice C reason: Suggesting that the voices won’t follow to a quiet room reinforces the hallucination as real. This is non-therapeutic because it validates the client’s distorted perception rather than helping them manage it.
Choice D reason: Telling the client “The voices are not real” is dismissive and can make the client feel misunderstood. It does not provide support or coping strategies, and directing them to group without addressing their immediate distress is inappropriate.
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