A nurse is caring for a client who is 2 days postpartum. Which of the following findings should the nurse report to the provider?

Scant lochia rubra with a few small clots

Urine output 2,500 mL/day

Bilateral ankle edema

4+ deep-tendon reflexes

Answer and Explanation

The Correct Answer is D

A. Scant lochia rubra with a few small clots. Lochia rubra is expected in the early postpartum period, and small clots are normal unless excessive bleeding occurs.
B. Urine output 2,500 mL/day. Increased urine output is expected postpartum as the body eliminates excess fluid retained during pregnancy.
C. Bilateral ankle edema. Mild edema is common postpartum due to fluid shifts and typically resolves on its own.
D. 4+ deep-tendon reflexes. Hyperreflexia is a sign of central nervous system irritability and may indicate preeclampsia, which requires immediate evaluation.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. "Store unused patches in the refrigerator." Scopolamine patches should be stored at room temperature, not in the refrigerator.
B. "Apply the patch prior to traveling." The patch should be applied at least four hours before travel to allow time for absorption and effectiveness.
C. "Place the patch on your upper arm." The patch should be applied behind the ear, not on the upper arm, for optimal absorption.
D. "Replace a dislodged patch onto the same location." A new patch should be applied to a different area to prevent skin irritation.

A. Keep the urinary bag at bladder level when ambulating. B. Loop the tubing so that it is lower than the collection bag. C. Obtain urinary samples by disconnecting the tubing connections. D. Secure the catheter to the client's thigh.

Correct Answer is D

Explanation

A. Keep the urinary bag at bladder level when ambulating. This is incorrect because the collection bag should always be kept below the bladder level to prevent backflow of urine, which can increase the risk of infection.
B. Loop the tubing so that it is lower than the collection bag. This is incorrect because kinking or looping the tubing can obstruct urine flow, leading to stasis and increasing the risk of bacterial growth and infection.
C. Obtain urinary samples by disconnecting the tubing connections. This is incorrect because disconnecting the system increases the risk of introducing bacteria. A sample should be obtained from the designated port using aseptic technique.
D. Secure the catheter to the client's thigh. This is correct because securing the catheter reduces movement and prevents urethral trauma, which lowers the risk of infection.

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A nurse is caring for a client who is 2 days postpartum. Which of the following findings should the nurse report to the provider?

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Naxlex Comprehensive Predictor Exams

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