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

4+ deep-tendon reflexes

Urine output 2.500 mL/day

Scant lochia rubra with a few small clots

Bilateral ankle edema

Answer and Explanation

The Correct Answer is A

A. 4+ deep-tendon reflexes: Deep-tendon reflexes are typically assessed using a scale ranging from 0 to 4+, with 4+ indicating hyperactive reflexes. In a postpartum client, hyperactive deep-tendon reflexes could indicate a potential complication such as preeclampsia or eclampsia, which require immediate medical attention. Therefore, the nurse should report this finding to the provider promptly.
B. Urine output 2,500 mL/day: A urine output of 2,500 mL/day is within the expected range for a postpartum client and does not require immediate intervention. Adequate urine output is important for assessing renal function and hydration status, but this finding does not indicate an urgent concern.
C. Scant lochia rubra with a few small clots: Scant lochia rubra with small clots is a normal finding in the early postpartum period. Lochia typically progresses from rubra (red) to serosa (pink) to alba (white) over time. As long as the lochia is not excessive or accompanied by large clots, this finding is not concerning and does not require immediate reporting to the provider.
D. Bilateral ankle edema: Mild bilateral ankle edema is common in the postpartum period and is often attributed to hormonal changes and shifts in fluid balance. While the nurse should continue to monitor for signs of worsening edema or other symptoms of preeclampsia, mild edema alone is not typically considered a critical finding requiring immediate reporting to the provider.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Preeclampsia: Preeclampsia is not a contraindication for the administration of misoprostol for induction of labor. In some cases, it may even be indicated to prevent complications associated with continuing the pregnancy.
B. Transverse fetal lie: A transverse fetal lie, where the baby is positioned sideways in the uterus, is a contraindication for the administration of misoprostol for induction of labor. Misoprostol is contraindicated when the fetal presentation is not cephalic (head down) due to the risk of complications, including cord prolapse.
C. Post-term pregnancy: Misoprostol is commonly used for induction of labor in post-term pregnancies, where the pregnancy has extended beyond 42 weeks. It helps initiate uterine contractions to stimulate labor and reduce the risk of complications associated with prolonged gestation.
D. Intrauterine growth restriction: Intrauterine growth restriction is not a contraindication for the administration of misoprostol for induction of labor. In such cases, the decision to induce labor would depend on various factors related to fetal well-being and maternal health.

A. The client reports that the restraints are too tight. B. The client has been in the restraints for 4hr. C. The client is able to calmly follow commands. D. The client can explain the reasons for their behavior.

Correct Answer is C

Explanation

A. The client reports that the restraints are too tight: This indicates a need for adjustment of the restraints but does not necessarily indicate that the restraints should be discontinued altogether. The client's ability to follow commands and behave safely is a more critical factor in deciding whether to discontinue the restraints.
B. The client has been in the restraints for 4 hours: While prolonged use of restraints should be avoided due to the risk of complications such as skin breakdown and loss of mobility, the duration alone may not be the sole indicator for discontinuing restraints. The client's behavior and ability to follow commands are more important considerations.
C. The client is able to calmly follow commands: This is the most appropriate finding indicating that the restraints should be discontinued. Calmly following commands suggests that the client's behavior has improved and they are no longer a danger to themselves or others, making the restraints unnecessary.
D. The client can explain the reasons for their behavior: While understanding the reasons for the client's behavior is important for addressing underlying issues, it does not necessarily indicate that the client is no longer a risk to themselves or others. The ability to calmly follow commands is a more immediate concern when deciding whether to discontinue restraints.

View Question and Answer

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

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

A nurse is reviewing the medical record of a client who has a prescription for misoprostol for induction of labor. Which of the following findings is a contraindication for administration of this medication?

Correct Answer is B

Explanation

A nurse is assessing a client who is in mechanical restraints after Hitting a staff member. Which of the following findings indicates that the nurse should discontinue the restraints?

Correct Answer is C

Explanation

A nurse at a health department is providing anticipatory guidance to the parent of a 1-month-old infant. The nurse should inform the parent that the infant should receive which of the following immunizations at the age of 2 months?

A nurse is teaching a client who is postpartum about caring for their newborn's umbilical cord. Which of the following instructions should the nurse include?

A charge nurse is evaluating a newly licensed nurse who is caring for a client who has measles. For which of the following actions by the newly licensed nurse should the charge nurse intervene?

A nurse is planning care for a client who is at 32 weeks of gestation and has severe preeclampsia. Which of the following actions should the nurse plan to take?

A community health nurse is providing education to a group of older adults about immunizations. Which of the following immunizations should the nurse recommend?

A nurse is planning care for a client who is undergoing brachytherapy with a low-dose radiation implant for treatment of prostate cancer. Which of the following interventions should the nurse include in the client's plan of care?

A nurse is providing discharge teaching to a client who is 1 day postoperative following a right modified radical mastectomy. Which of the following instructions should the nurse include in the teaching?