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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Correct Answer is D

Explanation

A. Tachypnea. Rapid breathing is associated with diabetic ketoacidosis (DKA) rather than mild hypoglycemia.
B. Ketonuria. The presence of ketones in the urine occurs with prolonged hyperglycemia and DKA, not with hypoglycemia.
C. Warm skin. Hypoglycemia typically causes cool, clammy skin due to sympathetic nervous system activation, not warmth.
D. Nervousness. Low blood glucose triggers the release of epinephrine, leading to symptoms such as nervousness, tremors, and sweating.

A. "Why do you think that alternative therapies are a better choice?" B. "You should consult with your family before seeking other treatments." C. "What has your doctor told you about your treatment options?" D. "I will come back to talk to you about your decision when you feel better."

Correct Answer is C

Explanation

A. Asking "Why do you think that alternative therapies are a better choice?" may come across as judgmental or challenging the client’s decision rather than supporting it. This is not therapeutic.
B. "You should consult with your family before seeking other treatments." assumes that the client’s decision depends on their family, which disregards autonomy.
C. "What has your doctor told you about your treatment options?" is an open-ended question that allows the client to express concerns while ensuring they have the necessary information to make an informed decision. This is the best response.
D. "I will come back to talk to you about your decision when you feel better." invalidates the client’s feelings and delays an important discussion.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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