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.

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Correct Answer is A

Explanation

A. Decreased impulsiveness: Methylphenidate is a central nervous system stimulant commonly used to treat attention deficit hyperactivity disorder (ADHD) in children. One of the therapeutic effects of methylphenidate is the reduction of impulsiveness, hyperactivity, and inattention, which are hallmark symptoms of ADHD. Therefore, a decrease in impulsiveness would indicate that the medication is effective.
B. Increased urine output: Methylphenidate is not expected to affect urine output. Increased urine output is not a typical finding indicating the effectiveness of methylphenidate.
C. Increased appetite: Methylphenidate commonly causes appetite suppression as a side effect. Therefore, an increase in appetite would not be indicative of the medication's effectiveness. In fact, a decrease in appetite is a common adverse effect of methylphenidate.
D. Decreased abdominal pain: Methylphenidate is not typically used to treat abdominal pain, and its effectiveness is not evaluated based on the relief of abdominal pain. The primary therapeutic effect of methylphenidate in ADHD is the improvement of attention, focus, and impulse control. Therefore, decreased abdominal pain would not be a reliable indicator of the medication's effectiveness.

A. A client who has a right peripherally inserted central catheter B. A client who had a right hemisphere stroke C. A client who had blood drawn from the right antecubital area 1 hr ago D. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm

Correct Answer is A

Explanation

A. A client who has a right peripherally inserted central catheter (PICC):
When a client has a right-sided PICC, it's essential to measure blood pressure in the left arm. This is because the PICC line can interfere with accurate blood pressure readings on the right side due to the placement of the cuff and potential obstruction of blood flow. Measuring blood pressure in the left arm provides a more accurate assessment of systemic blood pressure.

B. A client who had a right hemisphere stroke:
While clients with a right hemisphere stroke may have various neurological deficits, there is no specific indication to measure blood pressure in the left arm based solely on this condition.

C. A client who had blood drawn from the right antecubital area 1 hr ago:
Blood drawn from the antecubital area typically does not affect blood pressure measurements in the same arm. Therefore, there is no need to measure blood pressure in the opposite arm in this situation.

D. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm:
While clients with arteriovenous shunts may have altered blood flow dynamics, the use of a shunt in the left lower forearm does not necessarily require blood pressure measurements to be taken in the opposite arm. Blood pressure measurement should be performed on the side without the shunt unless contraindicated for other reasons.

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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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Correct Answer is A

Explanation

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