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. "You should wear a snug-fitting bra continuously for 72 hours": Wearing a snug-fitting bra continuously for 72 hours can help suppress lactation by providing support and reducing stimulation to the breasts. This can help prevent milk production and engorgement.
B. "You should apply moist heat to your breasts four times per day": Moist heat can stimulate milk production and should be avoided when trying to suppress lactation.
C. "You should limit your fluid intake to 1 liter per day": Adequate hydration is important for overall health, and limiting fluid intake to 1 liter per day is not advisable, especially postpartum when hydration needs may be higher.
D. "You should manually express milk when engorgement occurs": Manual expression of milk can stimulate milk production and should be avoided when attempting to suppress lactation. If engorgement occurs, cold compresses or ice packs can be used to reduce discomfort without stimulating milk production.

A. "I can expect my eyelids to be bruised after this procedure. B. "I will see dark spots in my vision after this procedure." C. I will receive general anesthesia for this procedure." D. I know the provider will replace the lens in my eyes during this procedure."

Correct Answer is D

Explanation

A. "I can expect my eyelids to be bruised after this procedure": Bruising of the eyelids is not a common expectation following cataract removal surgery. While mild redness or irritation may occur, significant bruising is not typical.
B. "I will see dark spots in my vision after this procedure": Seeing dark spots in vision after cataract removal surgery is not expected. The purpose of cataract surgery is to improve vision by removing the cloudy lens and replacing it with a clear artificial lens. Dark spots in vision may indicate complications such as retinal detachment, which should be promptly reported to the healthcare provider.
C. "I will receive general anesthesia for this procedure": Cataract removal surgery typically does not require general anesthesia. Instead, it is commonly performed under local anesthesia with sedation. General anesthesia is reserved for more complex or high-risk procedures. Therefore, this statement indicates a misunderstanding of the anesthesia type for cataract surgery.
D. "I know the provider will replace the lens in my eyes during this procedure": This statement indicates an accurate understanding of the cataract removal procedure. During cataract surgery, the cloudy natural lens of the eye is removed and replaced with an artificial intraocular lens (IOL) to restore vision. This is the primary goal of the surgery, and the statement reflects the client's understanding of the procedure.

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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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