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":"A"},"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 A

Explanation

Rationale:

A. Serum potassium: Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. Monitoring serum potassium is essential to detect elevated levels early and prevent cardiac complications.

B. Platelet count: Spironolactone does not significantly affect platelet production or function, so routine monitoring of platelets is not indicated for this medication.

C. Urine ketones: Ketone monitoring is relevant for clients with uncontrolled diabetes or ketosis, but it is not related to spironolactone therapy.

D. Total bilirubin: Bilirubin levels are used to assess liver function, which is not directly affected by spironolactone in most clients, so routine monitoring is not necessary unless the client has underlying hepatic disease.

A. Refute the client's delusions using logic. B. Give the client one simple direction at a time. C. Allow the client to choose among a variety of activities each day. D. Establish eye contact when communicating with the client. E. Reinforce orientation to time, place, and person.

Correct Answer is ["B","D","E"]

Explanation

A. Refute the client's delusions using logic: Confronting or trying to correct delusions can increase agitation and confusion in clients with dementia. This approach is not therapeutic and should be avoided.

B. Give the client one simple direction at a time: Providing clear, single-step instructions reduces confusion and helps the client successfully complete tasks, supporting independence and minimizing frustration.

C. Allow the client to choose among a variety of activities each day: Offering too many choices can overwhelm a client with dementia, leading to anxiety and agitation. It is more effective to offer a simple choice between two options or to provide a structured routine to reduce decision fatigue.

D. Establish eye contact when communicating with the client: Eye contact enhances attention, conveys respect, and improves comprehension during interactions, which is particularly important for clients with cognitive impairment.

E. Reinforce orientation to time, place, and person: Gentle reminders and reorientation cues help maintain cognitive function, reduce anxiety, and support the client’s awareness of their environment.

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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

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Correct Answer is A

Explanation

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Correct Answer is ["B","D","E"]

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.