A nurse is assisting with the care of a client.
Select the 3 findings that require immediate follow up
Heart rate
Pedal pulses
Breath sounds
Abdominal dressing
Respiratory rate
Oxygen saturation
Correct Answer : A,D,E
A. Heart rate: The increase from 88/min to 110/min indicates tachycardia, which can be an early sign of hypovolemia, infection, or sepsis. When combined with hypotension and fever, this finding suggests possible postoperative complications requiring urgent evaluation.
B. Pedal pulses: Bilateral pedal pulses remain 2+, indicating adequate peripheral perfusion at this time. This finding is stable and does not suggest acute circulatory compromise requiring immediate follow-up.
C. Breath sounds: Breath sounds are clear and unchanged from admission, suggesting no current pulmonary complication such as atelectasis or pneumonia. This finding does not indicate an urgent problem.
D. Abdominal dressing: A sudden increase to a large amount of serosanguinous drainage after the client felt something “pop” raises concern for wound dehiscence or possible evisceration. This is a surgical emergency requiring immediate assessment and intervention.
E. Respiratory rate: The respiratory rate has increased from 18/min to 24/min, indicating tachypnea. This may reflect pain, infection, or developing sepsis and warrants prompt follow-up in the postoperative client.
F. Oxygen saturation: Oxygen saturation remains within an acceptable range at 95% on room air. Although it should continue to be monitored, it does not currently indicate acute respiratory compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A hospital volunteer leaves the unit with the newborn to allow caregiver to rest: Hospital volunteers are not authorized to transport newborns, especially off the unit. Removing a newborn without proper clinical authorization represents a significant security risk and requires immediate initiation of a security alert to prevent potential abduction.
B. Another nurse on the unit requests to take the newborn to the nursery to obtain newborn screening: A licensed nurse transporting a newborn for required screening is an expected and appropriate practice. This follows standard hospital protocol and does not indicate a security concern when proper identification procedures are followed.
C. An assistive personnel weighs and bathes the newborn in an empty client room: Assistive personnel may perform routine newborn care under facility policy and nursing delegation. While supervision and proper identification are required, this situation alone does not necessitate a security alert.
D. The caregiver and newborn have matching hospital identification bracelets: Matching identification bands indicate that correct newborn identification procedures are in place. This supports infant safety and does not represent a situation requiring security intervention.
Correct Answer is D
Explanation
A. “I am so relieved the baby looks like my mother.”: Feeling relief or comfort when noticing family resemblance in the newborn is a common emotional response. It generally reflects normal adjustment and bonding with the baby and does not indicate emotional distress requiring further evaluation.
B. “My appetite has really increased.”: Increased appetite postpartum can be a normal physiological response, especially with breastfeeding, as the body requires additional calories. It does not usually indicate a mental health concern or a need for further evaluation.
C. “My labor was so long. I'm glad it's over.”: Expressing relief or fatigue after a prolonged labor is a typical postpartum response. It shows processing of the birth experience and adjustment to recovery and newborn care, which does not warrant immediate concern.
D. “I really wish I had a girl instead.”: Expressing regret or disappointment regarding the baby’s sex may indicate difficulty bonding, gender preference stress, or emerging postpartum mood disturbances. This statement warrants further assessment for postpartum depression, anxiety, or adjustment issues to ensure maternal-infant wellbeing.
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