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)
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. This image shows Heberden's and Bouchard's nodes, which are bony enlargements of the finger joints typically associated with Osteoarthritis.
B. This image clearly shows the loss of the normal angle between the nail and the nail bed (Lovibond angle). The fingertips appear enlarged and "drumstick-like," and the nails have a distinct downward, convex curvature.
C. This image displays Ulnar Drift (the fingers slanting toward the pinky side) and joint swelling, which are classic manifestations of Rheumatoid Arthritis. It also shows age-related lentigines (liver spots) on the skin.
Correct Answer is D
Explanation
A. Visual Analog Scale: The visual analog scale requires the child to understand and mark a point on a line representing pain intensity. This scale is appropriate for older children, usually around 7 years and older, and not for an 8-month-old infant.
B. FACES pain scale: The FACES scale uses facial expressions to help children identify pain intensity, but it is suitable for children aged 3 years and older who can understand the concept of choosing a face to represent their pain.
C. Oucher scale: The Oucher scale also relies on the child’s ability to self-report pain by selecting a photograph or numerical representation. It is not appropriate for infants who cannot communicate their pain cognitively.
D. FLACC scale: The FLACC scale assesses pain in infants and young children by observing five criteria: Face, Legs, Activity, Cry, and Consolability. It allows the nurse to evaluate pain objectively in an 8-month-old who cannot verbally self-report.
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