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 B

Explanation

A. "Did anything in particular make you feel this way?" - While exploring potential triggers for the client's feelings of uselessness is important, assessing for suicidal ideation takes precedence. However, this question can be asked after addressing the immediate safety concern.
B. "Do you ever think about harming yourself?" - This is the priority assessment question. Older adults experiencing feelings of uselessness and worthlessness may be at risk for suicidal ideation or self-harm. Asking about thoughts of self-harm allows the nurse to assess the client's safety and determine the need for immediate intervention.
C. "How long have you had these feelings of uselessness?" - While understanding the duration of the client's feelings is relevant, assessing for suicidal ideation is more critical in ensuring the client's safety.
D. "Would you tell me more about the changes you see in your body?" - Exploring the client's perception of physical changes is important for addressing body image concerns and promoting self-esteem. However, assessing for suicidal ideation takes precedence as it addresses the client's immediate safety.

A. A bologna sandwich on rye bread B. corn tortilla with black beans C. Whole wheat pasta with shrimp D. Low sodium vegetable soup with barley

Correct Answer is B

Explanation

A. A bologna sandwich on rye bread: Rye bread contains gluten, which is harmful to individuals with celiac disease. Therefore, foods containing gluten, such as rye bread, should be avoided in the diet of a preschooler with celiac disease.
B. Corn tortilla with black beans: Corn tortillas and black beans are both gluten-free options and suitable for individuals with celiac disease. Corn tortillas are made from cornmeal, which does not contain gluten, making them a safe choice for individuals with celiac disease. Black beans are also naturally gluten-free and can provide essential nutrients like protein and fiber to the preschooler's diet.
C. Whole wheat pasta with shrimp: Whole wheat pasta contains gluten, which is not suitable for individuals with celiac disease. Therefore, whole wheat pasta should be avoided in the diet of a preschooler with celiac disease.
D. Low sodium vegetable soup with barley: Barley contains gluten and is not suitable for individuals with celiac disease. Therefore, foods containing barley, such as vegetable soup with barley, should be avoided in the diet of a preschooler with celiac disease.

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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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