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
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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Related Questions
Correct Answer is C
Explanation
A. Reinserting the protruding intestinal tissue is inappropriate and can cause further injury or infection. The nurse should keep the tissue moist and protected until surgical intervention.
B. Placing the client in Trendelenburg position is incorrect because it does not reduce tension on the wound. Instead, the client should be placed in a low Fowler's position with knees slightly flexed to reduce strain.
C. Covering the wound with a sterile saline-soaked dressing is the priority action to keep the tissue moist and prevent further contamination or damage until the provider can intervene.
D. Monitoring vital signs every 30 minutes is important but not the priority action. The nurse should immediately cover the wound first, then monitor for signs of shock or infection.
Correct Answer is A
Explanation
A. A bluish-white colored pupil. This is correct because cataracts cause clouding of the lens, leading to a grayish or bluish-white appearance of the pupil. This opacity gradually impairs vision.
B. Decrease in peripheral vision. This is incorrect because a loss of peripheral vision is characteristic of glaucoma, not cataracts.
C. Increased intraocular pressure. This is incorrect because increased intraocular pressure is a hallmark of glaucoma, not cataracts.
D. Loss of central vision. This is incorrect because central vision loss is associated with macular degeneration rather than cataracts.
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