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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Constipation is a common side effect of risperidone due to its anticholinergic effects. However, it is not the priority because it is not immediately life-threatening.
B. Visual disturbances can occur with risperidone, but they are not as urgent as cardiovascular abnormalities.
C. Dry mouth is another anticholinergic side effect, but it is not a priority concern compared to an irregular pulse.
D. Irregular pulse is the priority finding because risperidone can prolong the QT interval, increasing the risk of serious cardiac arrhythmias, including torsades de pointes, which can be life-threatening. Therefore, this finding should be reported to the provider immediately.
Correct Answer is C
Explanation
A. The guardian wants to accompany the child from the ED to the radiology department. This is a typical parental response and does not indicate maltreatment. Parents often want to stay with their child for reassurance.
B. The guardian states the child fell off the swing in the backyard. This is a plausible explanation for an injury in a preschooler, though the consistency of the story with the injury should still be assessed.
C. The child was brought to the ED 2 days after the injury occurred. A delay in seeking medical care for a significant injury is a potential warning sign of child maltreatment and warrants further investigation.
D. The child cries loudly when their arm is moved or manipulated. Pain with movement is expected with a fracture and does not indicate maltreatment.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.