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. Loss of central vision: While loss of central vision can occur with various eye conditions, such as age-related macular degeneration, it is not specific to cataracts. Cataracts typically cause clouding of the lens, leading to blurred or dimmed vision rather than loss of central vision.
B. Increased intraocular pressure: Increased intraocular pressure is characteristic of conditions such as glaucoma, not cataracts. Cataracts involve clouding of the lens rather than elevated pressure within the eye.
C. Decrease in peripheral vision: Decreased peripheral vision is associated with conditions like retinitis pigmentosa or glaucoma but is not a typical finding in cataracts. Cataracts primarily affect visual acuity and clarity rather than peripheral vision.
D. A bluish-white colored pupil: A bluish-white appearance of the pupil, known as leukocoria or a white pupil reflex, can be indicative of cataracts. It occurs due to light scattering by the cloudy lens of the eye, resulting in an abnormal reflection from the pupil. This finding is characteristic of cataracts and warrants further evaluation by an ophthalmologist.

A. Acute hemolytic B. Allergic C. Bacterial D. Febrile nonhemolytic

Correct Answer is A

Explanation

A. Acute hemolytic:
Acute hemolytic transfusion reactions typically present with symptoms such as fever, chills, flank pain, hemoglobinuria (blood in the urine), and possibly hypotension. This occurs due to the rapid destruction of transfused red blood cells, often because of ABO incompatibility between the donor and recipient. The symptoms described in the scenario, including chest tightness, are not consistent with acute hemolytic reactions.

B. Allergic:
Allergic reactions to blood transfusions can manifest with symptoms such as itching, hives, flushing, and mild respiratory distress. While headache and low-back pain can occur in allergic reactions, the feeling of "tightness" in the chest is more indicative of another type of reaction.

C. Bacterial:
Bacterial contamination of blood products can lead to transfusion-related sepsis. Symptoms may include fever, chills, hypotension, and rapid onset of shock. However, the presence of headache and low-back pain, along with chest tightness, is not typically associated with bacterial contamination.

D. Febrile nonhemolytic:
Febrile nonhemolytic transfusion reactions are characterized by fever, chills, and rigors. While fever and chills are common symptoms, they do not typically cause chest tightness or low-back pain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing an eye examination on a client. Which of the following findings should indicate to the nurse that the client might have cataracts?

Correct Answer is D

Explanation

A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low-back pain, and a feeling of "tightness" in their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?

Correct Answer is A

Explanation

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