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A nurse is assisting with the care of client who is 6 hr postoperative. Which of the following findings should the nurse report to the provider?

A.

Serosanguinous drainage on dressing

B.

Hypoactive bowel sounds

C.

Urinary output of 25 mL/hr

D.

Pain level of 2 on 0 to 10 scale

Answer and Explanation

The Correct Answer is C

A. Serosanguinous drainage on dressing: Serosanguinous drainage, which is a mixture of clear and blood-tinged fluid, is a common and expected finding in the early postoperative period. It typically indicates normal healing unless the amount becomes excessive or the drainage changes character.

B. Hypoactive bowel sounds: Hypoactive bowel sounds are common within the first 24 to 48 hours following surgery, especially after general anesthesia or abdominal procedures. This finding is expected and does not immediately require provider notification unless accompanied by other concerning signs like severe abdominal distention.

C. Urinary output of 25 mL/hr: Urinary output should be at least 30 mL/hr to indicate adequate kidney perfusion and hydration. An output of 25 mL/hr suggests possible hypovolemia, renal impairment, or urinary retention, and it should be promptly reported to the provider for further evaluation.

D. Pain level of 2 on 0 to 10 scale: A pain score of 2 indicates mild pain, which is manageable and expected after surgery. This level of discomfort does not require urgent reporting to the provider as long as it remains controlled and does not interfere with recovery activities.


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Related Questions

Correct Answer is A

Explanation

A: Image A shows an injection being prepared at the deltoid muscle, which is the correct site and technique for administering the tetanus and diphtheria (Td) vaccine. The Td vaccine should be given intramuscularly, typically into the deltoid muscle of the upper arm in adults, using a 90-degree angle to ensure proper muscle penetration.

B: Image B shows an injection technique appropriate for intradermal or possibly subcutaneous injection, indicated by the shallow angle of insertion into the skin. This method is not correct for a Td vaccine, which requires intramuscular administration for proper absorption and effectiveness.

Correct Answer is D

Explanation

A. Hyperbilirubinemia: Hyperbilirubinemia in neonates is commonly due to immature liver function and the breakdown of red blood cells after birth. It is not linked to maternal folic acid deficiency and would not be prevented through maternal folic acid supplementation.

B. Hyperemesis gravidarum: Hyperemesis gravidarum is a severe form of nausea and vomiting that occurs during pregnancy, affecting the mother rather than the neonate. Folic acid supplementation does not prevent this condition, as it is more related to hormonal changes during pregnancy.

C. Iron deficiency anemia: Iron deficiency anemia occurs when there is an inadequate amount of iron, not folic acid, in the mother’s or infant’s diet. While iron is important during pregnancy for both the mother and the developing fetus, folic acid deficiency primarily affects neural tube development, not iron levels or red blood cell production in the same way. Iron supplementation is recommended during pregnancy to prevent iron deficiency anemia.

D. Neural tube defects: Neural tube defects, such as spina bifida and anencephaly, are directly linked to folic acid deficiency during early pregnancy. Adequate folic acid intake before conception and during early pregnancy significantly reduces the risk of these serious birth defects affecting the brain and spine.

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