A nurse is assisting in the care of a client on a postpartum unit. The client had an uncomplicated vaginal delivery 24 hours ago. Which of the following data collection findings should the nurse report to the primary RN immediately?
Moderate lochia rubra on the pad
Nipple tenderness with breastfeeding
Hemorrhoids on the rectal area
Calf edematous and tender
The Correct Answer is D
A. Moderate lochia rubra on the pad: Moderate lochia 24 hours postpartum is considered a normal finding as the uterus continues to shed the lining. It typically appears bright red and gradually decreases over the following days, so it does not require immediate reporting.
B. Nipple tenderness with breastfeeding: Nipple tenderness is common in the early postpartum period due to breastfeeding, especially if the latch is not optimal. While it should be addressed to prevent complications, it is not an urgent finding requiring immediate reporting.
C. Hemorrhoids on the rectal area: Hemorrhoids are a frequent postpartum occurrence, often resulting from vaginal delivery or straining during labor. They are uncomfortable but not emergent, so they do not need immediate reporting.
D. Calf edematous and tender: A calf that is swollen, edematous, and tender may indicate a deep vein thrombosis (DVT), which is a potentially life-threatening postpartum complication. This finding requires immediate reporting to the primary RN for timely assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Gently massage the eyelid to facilitate absorption of the medication: Massaging the eyelid is not recommended because it can spread the infection to surrounding tissues and increase irritation. Medication should remain in the conjunctival sac for absorption.
B. Wipe any excess medication from the inner canthus outward: After applying ophthalmic ointment, wiping from the inner canthus (near the nose) outward prevents contamination of the tear duct and reduces the risk of spreading the infection to the other eye or face.
C. Instruct guardian to apply erythromycin ophthalmic ointment every morning for 14 days: The prescribed medication is bacitracin, not erythromycin. Providing the correct drug and following the prescribed dosing schedule is essential for effective treatment.
D. Place an occlusive dressing on the affected eye to prevent the spread of infection: An occlusive dressing is not indicated for bacterial conjunctivitis. Proper hand hygiene and avoiding contact with the eye are sufficient to prevent transmission.
Correct Answer is D
Explanation
A. Gown: Gowns are typically used to protect against contact with infectious body fluids or contaminated surfaces. Tuberculosis is primarily transmitted via airborne droplets, so gowns are not required for routine care of a client with suspected TB.
B. Gloves: Gloves protect against direct contact with infectious materials or bodily fluids. While gloves may be used during procedures involving secretions, they are not the primary protective equipment for preventing inhalation of airborne TB particles.
C. Dosimeter badge: Dosimeter badges monitor exposure to ionizing radiation and are irrelevant in the context of airborne infectious diseases like tuberculosis. Wearing a dosimeter does not protect against TB transmission.
D. N95 respirator: An N95 respirator is specifically designed to filter airborne particles, including Mycobacterium tuberculosis. Nurses must wear an N95 respirator when entering the room of a client with suspected or confirmed TB to prevent inhalation of infectious droplets.
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