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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.

A.

Blood pressure

B.

Skin temperature

C.

Fundal assessment

D.

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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Related Questions

Correct Answer is D,B,E,C,A

Explanation

Rationale:

A. Record information about the home visit according to agency policy: Documentation is performed at the end of the visit to ensure that all observations, interventions, and plans are accurately recorded in the client’s record for continuity of care.

B. Contact the family to determine availability and readiness to make an appointment: Before visiting, the nurse should coordinate with the family to schedule a convenient time, ensuring that they are prepared for the assessment and intervention process.

C. Discuss plans for future visits with the family: After assessing the client and identifying needs, the nurse should collaborate with the family to plan ongoing visits and care strategies that align with their goals and availability.

D. Clarify the reason for the referral with the provider's office: This is the first step to ensure the nurse understands the purpose of the referral, specific concerns, and any important background information before contacting the family.

E. Identify family needs and interventions using the nursing process: During the visit, the nurse collects data, assesses needs, and develops appropriate interventions, forming the foundation for the care plan moving forward.

Correct Answer is B

Explanation

Rationale:

A. Perform an ECG every 12 hr: Frequent ECGs are typically done during the acute phase to monitor for arrhythmias, but by day 3 post-MI, continuous or as-needed monitoring is more appropriate unless new symptoms occur.

B. Obtain a cardiac rehabilitation consultation: Early involvement of cardiac rehab supports gradual activity progression, lifestyle modification, and psychosocial support, improving long-term outcomes after MI.

C. Draw a troponin level every 4 hr: Troponin testing is most useful for diagnosing and trending damage during the first 24 hours; by day 3, levels have usually peaked and are declining.

D. Place the client in a supine position while resting: Supine positioning can increase cardiac workload; a semi-Fowler's position is preferred to reduce venous return and ease breathing.

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