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 A
Explanation
A. The client: A married 17-year-old is considered emancipated in most states and has the legal authority to provide informed consent for their own medical care, including surgery. The nurse should obtain the client’s signature to confirm understanding and voluntary agreement.
B. The client's provider: The provider performs the procedure and is responsible for explaining the risks, benefits, and alternatives, but does not sign the consent on behalf of the client.
C. The client's partner: A spouse or partner does not have legal authority to consent for an emancipated minor unless specifically granted by law, so the partner’s signature is not required.
D. The client's caregiver: A parent or guardian would normally provide consent for a minor, but an emancipated minor has independent legal authority, making caregiver consent unnecessary in this scenario.
Correct Answer is ["125"]
Explanation
Total Volume: 1,000 mL
Infusion Time: 8 hours
- Calculate the infusion rate
Infusion Rate (mL/hr) = Total Volume ÷ Time (hr)
Infusion Rate = 1,000 ÷ 8
Infusion Rate = 125 mL/hr
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