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 D

Explanation

A. "I'll replace the batteries every 2 weeks." - This statement is incorrect. While it's essential to replace hearing aid batteries regularly, the frequency of battery replacement depends on factors such as battery type, usage, and the specific needs of the individual. Providing a specific timeframe like "every 2 weeks" may not be accurate for all clients.
B. "I'll use isopropyl alcohol to clean my hearing aids." - This statement is incorrect. Isopropyl alcohol can damage hearing aids as it may degrade plastic components or affect the adhesives used in their construction. Instead, clients should use a soft, dry cloth or a specialized hearing aid cleaning tool recommended by their audiologist.
C. "I'll clean my ear with cotton swabs before I insert my hearing aids." - This statement is incorrect. Using cotton swabs to clean the ear canal can push earwax deeper into the ear canal, potentially impacting it and interfering with hearing aid function. Clients should avoid inserting anything into their ear canal and consult with their healthcare provider if earwax buildup is a concern.
D. "It will disconnect the battery when I remove my hearing aids." - This statement is correct. Many behind-the-ear (BTE) hearing aids are designed to disconnect the battery when removed from the ear, helping to conserve battery life when not in use. This understanding indicates that the client grasps an essential aspect of caring for their hearing aids.

A. Human papillomavirus (HPV) B. Rotavirus C. Herpes zoster D. Diphtheria, tetanus, and acellular pertussis (DTaP)

Correct Answer is C

Explanation

A. Human papillomavirus (HPV): HPV vaccination is typically recommended for adolescents and young adults to prevent HPV infection, which can lead to cervical cancer and other related diseases. It is not typically indicated for older adults.
B. Rotavirus: Rotavirus vaccination is recommended for infants to protect against severe diarrhea caused by rotavirus infection. It is not indicated for older adults.
C. Herpes zoster: Herpes zoster vaccination, also known as the shingles vaccine, is recommended for older adults to prevent shingles, a painful rash caused by the reactivation of the varicella-zoster virus. The risk of developing shingles increases with age, and vaccination can reduce the risk and severity of the condition.
D. Diphtheria, tetanus, and acellular pertussis (DTaP): DTaP vaccination is typically administered to children to protect against diphtheria, tetanus, and pertussis (whooping cough). Tdap is the vaccine formulation recommended for adults, which includes tetanus, diphtheria, and pertussis components.

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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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