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","C","D","G"]

Explanation

System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

Rationale

These findings suggest significant cognitive and physical decline, potential depression, and possible suicidal ideation, all of which require immediate attention and intervention.

A. “It is important that our child avoids placing anything inside the cast.” B. “We should notify the provider if the cast becomes loose over time.” C. “We should prop the casted arm on pillows for the next 24 hours.” D. “We need to be very careful about how we handle the cast for the first 2 days while it dries.”

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

“It is important that our child avoids placing anything inside the cast.”: This reflects an understanding. Inserting objects inside the cast can cause injury, skin breakdown, or infection, and should be avoided.

“We should notify the provider if the cast becomes loose over time.”: This reflects an understanding. A loose cast could lead to inadequate immobilization or further injury. Parents should report any loosening to the provider.

“We should prop the casted arm on pillows for the next 24 hours.”: This needs reinforcement. The cast should be elevated to reduce swelling, but it should not be kept elevated for 24 hours continuously. Parents should be taught to elevate the arm in intervals and monitor for signs of increased swelling or discomfort.

“We need to be very careful about how we handle the cast for the first 2 days while it dries.”: This reflects an understanding. It is important to handle the cast with care while it is drying to prevent deformities or indentations in the cast that could interfere with proper healing.

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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.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","D","G"]

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

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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.