A nurse is assisting with the care of a client who is 24 hours following a vaginal birth. Which of the following findings should the nurse report to the RN?

Fundus is located 2 cm (0.4 in) below the level of the umbilicus

Scant lochia rubra on the perineal pad

Non-pitting bilateral peripheral edema

Oral temperature of 38.8° C (101)

Answer and Explanation

The Correct Answer is D

A. Fundus is located 2 cm (0.4 in) below the level of the umbilicus: A fundus slightly below the umbilicus 24 hours postpartum is expected as the uterus involutes. This is a normal finding and does not require immediate reporting unless accompanied by excessive bleeding or other concerning signs.

B. Scant lochia rubra on the perineal pad: Scant lochia rubra is typical within the first 24 hours postpartum, indicating normal uterine shedding. It is expected and does not indicate a complication in the absence of heavy bleeding or foul odor.

C. Non-pitting bilateral peripheral edema: Mild non-pitting edema in the lower extremities can occur postpartum due to fluid shifts and is usually self-limiting. It is not typically emergent unless accompanied by severe swelling, pain, or signs of deep vein thrombosis.

D. Oral temperature of 38.8° C (101° F): An elevated temperature above 38° C 24 hours postpartum may indicate infection, such as endometritis or urinary tract infection. This finding requires immediate reporting to the RN for further assessment and intervention.

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Correct Answer is D

Explanation

A. Improved respiratory function: Pancrelipase is a digestive enzyme replacement and does not directly improve lung function. Respiratory management in cystic fibrosis requires separate interventions such as airway clearance and inhaled medications.

B. Improved absorption of vitamins B and C: Pancrelipase primarily aids in the digestion of fats, proteins, and carbohydrates. While it improves absorption of fat-soluble vitamins (A, D, E, K), it does not specifically enhance absorption of water-soluble vitamins like B and C.

C. Decreased sodium excretion: Pancrelipase does not influence electrolyte excretion, including sodium. Electrolyte management in cystic fibrosis requires separate monitoring and supplementation as needed.

D. Reduced fat in the stools: The therapeutic effect of pancrelipase is to aid digestion of fats, reducing steatorrhea (fatty stools). Successful treatment improves nutrient absorption and decreases gastrointestinal symptoms related to fat malabsorption.

A. Make a schedule of daily tasks. B. Have several family members visit daily. C. Limit the use of familiar objects. D. Ask questions that require more than one answer.

Correct Answer is A

Explanation

A. Make a schedule of daily tasks: Establishing a consistent daily routine helps reduce confusion and frustration in clients with Alzheimer's disease. Predictable schedules provide structure, promote independence, and create a sense of security.

B. Have several family members visit daily: While social interaction is important, having too many visitors at once or a constant rotation of people can lead to overstimulation. For a client with Alzheimer's, high-stimulus environments often trigger agitation, confusion, or "sundowning.

C. Limit the use of familiar objects: Surrounding the client with meaningful items—such as family photos, a favorite chair, or personal mementos—helps with reorientation and provides emotional comfort. Removing these objects can increase the client's sense of isolation and disorientation, leading to greater frustration.

D. Ask questions that require more than one answer: Complex questions may be difficult for the client to answer, potentially causing frustration. Simple, clear questions are more appropriate to promote communication and reduce stress.

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A nurse is assisting with the care of a client who is 24 hours following a vaginal birth. Which of the following findings should the nurse report to the RN?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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