A nurse is caring for a client who is 1 hr postpartum.

Exhibits

For each assessment finding, click to specify if the finding indicates the client's condition has improved or remains unchanged. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Blood pressure

Skin temperature

Fundal assessment

Bleeding

Answer and Explanation

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

Blood pressure: At 2100, the client’s BP was 90/56 mm Hg, indicating hypotension likely from postpartum hemorrhage. By 2115, BP increased to 108/72 mm Hg, showing improved hemodynamic stability after interventions such as fundal massage, oxytocin administration, and bladder emptying.
Skin temperature: At both 2100 and 2115, the client’s skin remained cool to the touch. This could indicate ongoing peripheral vasoconstriction or residual hypoperfusion, suggesting that although circulation improved, thermoregulation and peripheral perfusion have not fully normalized.
Fundal assessment: Initially, the fundus was boggy, deviated to the right, and 2 cm above the umbilicus, indicating uterine atony worsened by bladder distention. After catheterization and uterotonic therapy, the fundus became midline, firm, and at the level of the umbilicus, which is expected postpartum and reduces bleeding risk.
Bleeding: At 2100, there was heavy lochia rubra saturating a perineal pad in 20 min with passage of a large clot. At 2115, bleeding decreased to a moderate amount of lochia rubra with a few pea-sized clots, indicating that hemorrhage control measures were effective.

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Correct Answer is D

Explanation

A. The client is allergic to penicillin: Medication allergies are critical for the nurse and prescriber to know, but they are not directly relevant to occupational therapy planning.

B. The client's parent is in a skilled nursing facility: While this may influence social support, it is not directly relevant to the client’s rehabilitation needs or adaptive strategies for activities of daily living.

C. The client has two small children at home: Knowing family responsibilities can help plan overall care, but the specific home environment is more critical for occupational therapy interventions.

D. The client lives in a two-story home: The home environment, including stairs, affects mobility, accessibility, and safety after amputation. Reporting this information is essential for planning adaptive equipment, home modifications, and safe discharge.

A. "A living will is a document that includes my wishes about health care decisions." B. "My partner needs to be present as a witness when I sign a living will." C. "My provider will make my health care decisions if I complete advance directives." D. "Advance directives outline who inherits my material possessions in the event of my death."

Correct Answer is A

Explanation

A. "A living will is a document that includes my wishes about health care decisions.": A living will is an advance directive that specifies a client’s preferences for medical treatment in situations where they are unable to communicate.

B. "My partner needs to be present as a witness when I sign a living will.": Witness requirements vary by state, and typically a neutral adult, not necessarily a partner, must witness the signing.

C. "My provider will make my health care decisions if I complete advance directives.": Advance directives are intended to communicate the client’s own wishes, not delegate decision-making solely to the provider. The provider’s role is to follow the client’s documented preferences.

D. "Advance directives outline who inherits my material possessions in the event of my death.": Inheritance is addressed in a will, not advance directives. Advance directives focus exclusively on medical and end-of-life care decisions.

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A nurse is caring for a client who is 1 hr postpartum. Exhibits For each assessment finding, click to specify if the finding indicates the client's condition has improved or remains unchanged. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is recovering from an amputation of her right arm below the elbow. Which of the following information should the nurse report to the occupational therapist?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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A nurse is caring for a client who is 1 hr postpartum.

Exhibits

For each assessment finding, click to specify if the finding indicates the client's condition has improved or remains unchanged. There must be at least 1 selection in every row. There does not need to be a selection in every column.