A nurse is caring for a client.

Exhibits

The nurse is caring for a client on the postpartum unit.

The nurse is caring for the client following an emergency cesarean birth. Which of the following findings indicate an improvement in the client's condition?

Select all that apply.

Hemoglobin

Heart rate

Pain level

Temperature

Vaginal bleeding

Blood pressure

Answer and Explanation

Correct Answer : B,C,E,F

A. Hemoglobin: Although an improvement in hemoglobin would be ideal, it may take more time to see a significant change after blood loss or transfusion. A rise in hemoglobin indicates that the body is recovering from blood loss, but it is not as immediate an indicator of improvement as other factors, such as heart rate or blood pressure stabilization.

B. Heart rate: A decrease in the heart rate toward the normal range (60-100 beats/min) indicates improvement in the client's condition. The initial heart rate of 120-128 beats/min (tachycardia) suggests the client may have been compensating for blood loss or pain. A more stable heart rate would suggest a response to treatment and improvement in their cardiovascular status.

C. Pain level: A reduction in pain score is an important indicator of recovery post-surgery. After an emergency cesarean birth, pain management is a critical aspect of recovery, and a reduction in pain intensity would suggest that the client is improving and responding well to pain management interventions.

D. Temperature: A normal temperature would suggest no infection or complications. However, temperature changes in the immediate postpartum period can be influenced by various factors (e.g., infection, hormonal changes, or recovery from surgery). It is not as immediate an indicator of recovery as heart rate or blood pressure.

E. Vaginal bleeding: A decrease in vaginal bleeding, especially after a cesarean, would indicate that bleeding is being effectively controlled and the uterus is contracting appropriately, reducing the risk of hemorrhage or complications like uterine atony.

F. Blood pressure: A return to normal blood pressure levels (e.g., closer to the pre-pregnancy baseline) would indicate that the client's circulatory status is stabilizing. The dropping blood pressure seen earlier (from 95/62 mm Hg to 85/48 mm Hg) indicated hypovolemic shock or a response to blood loss, so stabilization and an increase in blood pressure would be a positive sign.

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Correct Answer is B

Explanation

A. Keeping the television on at night can cause confusion and disrupt sleep patterns, increasing the risk of injury.

B. Assisting the client to the toilet frequently can prevent falls and reduce the risk of incontinence-related injuries.

C. Raising side rails may increase the risk of injury due to falls or entrapment.

D. Placing the bedside table at the foot of the bed may lead to confusion and increase fall risk.

A. Wear a face shield prior to entering the client's room. B. Place a mask on the client prior to transport. C. Use an alcohol-based hand rub following client care. D. Remove the protective gown while in the client's room.

Correct Answer is D

Explanation

A. A face shield is unnecessary unless there is a risk of splashing.

B. Masks are not needed for C. difficile, as it is not spread through airborne transmission.

C. Alcohol-based hand rubs are ineffective against C. difficile spores; handwashing with soap and water is required.

D. Contact precautions for C. difficile require the nurse to remove the protective gown and gloves inside the client's room to prevent contamination of outside areas.

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A nurse is caring for a client. Exhibits The nurse is caring for a client on the postpartum unit. The nurse is caring for the client following an emergency cesarean birth. Which of the following findings indicate an improvement in the client's condition? Select all that apply.

Nursing Test Bank

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A nurse is caring for a client.

Exhibits

The nurse is caring for a client on the postpartum unit.

The nurse is caring for the client following an emergency cesarean birth. Which of the following findings indicate an improvement in the client's condition?

Select all that apply.