A nurse is caring for a 32-year-old female client in the postpartum unit who had a cesarean birth due to preeclampsia. The client has been prescribed misoprostol.
Exhibits
The nurse is assessing the client 1 hour later. How should the nurse interpret the findings?
For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
Fundus 2 cm above umbilicus
Blood pressure 90/60 mm Hg
Heart rate 110/min
Continued heavy vaginal bleeding
Client reports feeling dizzy
Cloudy urine
The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"A"}}
• Fundus 2 cm above umbilicus: This could be a sign of potential worsening condition as it might indicate uterine atony, a condition in which the uterus fails to contract after the delivery, leading to continuous bleeding.
• Blood pressure 90/60 mm Hg: This could be an indication of potential improvement as it is within the normal range, and lower than the previous reading which was elevated due to preeclampsia.
• Heart rate 110/min: This could be a sign of potential worsening condition as it is slightly elevated, which could be a response to blood loss.
• Continued heavy vaginal bleeding: This could be a sign of potential worsening condition as it might indicate postpartum hemorrhage.
• Client reports feeling dizzy: This could be a sign of potential worsening condition as it might be due to blood loss leading to decreased perfusion to the brain.
• Cloudy urine: This is unrelated to the diagnosis. It could be due to dehydration or a urinary tract infection, but it’s not directly related to preeclampsia or postpartum hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Raw carrots do not contain vitamin B12. Vitamin B12 is not naturally found in plant foods.
Choice B rationale
Fresh citrus fruits do not contain vitamin B12. Vitamin B12 is not naturally found in plant foods.
Choice C rationale
This is the correct answer. Fortified soy milk is a good source of vitamin B12 for vegans. Many brands of soy milk are fortified with vitamin B12 and other nutrients to help vegans meet their nutritional needs.
Choice D rationale
Brown rice does not contain vitamin B12. Vitamin B12 is not naturally found in plant foods.
Correct Answer is D
Explanation
Choice A rationale
While breast tenderness can be a side effect of oral contraceptives, it is not typically a sign of a serious problem. It may occur as the body adjusts to the hormones in the medication.
However, if the tenderness is severe or persists, the client should consult their healthcare provider.
Choice B rationale
Pain during intercourse is not typically associated with the use of oral contraceptives. If a client experiences this symptom, it may be due to other causes such as infection, inflammation, or certain medical conditions. It’s important to seek medical advice if this symptom occurs.
Choice C rationale
Unusual vaginal discharge can be a side effect of oral contraceptives, but it is not typically a sign of a serious problem. Changes in the color, consistency, or smell of vaginal discharge could indicate an infection or other medical condition and should be evaluated by a healthcare provider.
Choice D rationale
Severe abdominal pain is a symptom that the client should report to the provider immediately. This could be a sign of a serious problem such as a blood clot or liver disease. It’s important to seek immediate medical attention if this symptom occurs.
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