A nurse is caring for a client who is 2 hr postoperative. Which of the following findings should the nurse report to the provider?

The client reports a pain level of 2 on a 0 to 10 scale after administration of pain medication.

The client has a urine output of 50 mL/hr after removal of the indwelling urinary catheter.

The client has a wound dressing saturated with sanguinous drainage after it was reinforced.

The client has an oxygen saturation level of 96% after oxygen 2 L/min via nasal cannula was applied.

Answer and Explanation

The Correct Answer is C

Rationale:
A. The client reports a pain level of 2 on a 0 to 10 scale after administration of pain medication: A pain level of 2 indicates adequate pain control following surgery, showing that the prescribed analgesic regimen is effective. This finding does not require reporting.

B. The client has a urine output of 50 mL/hr after removal of the indwelling urinary catheter: A urine output of 50 mL/hr is within normal limits and indicates adequate renal perfusion. This finding suggests that kidney function and fluid balance are appropriate after surgery.

C. The client has a wound dressing saturated with sanguineous drainage after it was reinforced: Saturation of the surgical dressing with sanguineous drainage can indicate active bleeding or hemorrhage. Because this exceeds normal postoperative drainage and persists after reinforcement, it requires immediate notification of the provider.

D. The client has an oxygen saturation level of 96% after oxygen 2 L/min via nasal cannula was applied: An oxygen saturation of 96% indicates effective oxygenation and a positive response to therapy. This finding is within normal range and does not signal a complication.

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Correct Answer is A

Explanation

Rationale:
A. The client started working in a parking garage 3 months ago: Working in a parking garage may expose the client to exhaust fumes and carbon monoxide, which are hazardous during pregnancy. This environment increases the risk of fetal hypoxia and warrants further evaluation for occupational safety and potential exposure mitigation.

B. The client is doing 30 min of moderate exercise daily: Moderate exercise during pregnancy is generally safe and encouraged to promote maternal health, improve circulation, and reduce gestational complications. This activity does not indicate unsafe behavior.

C. The client is drinking 2.5 L of water per day: Adequate hydration is recommended during pregnancy to support maternal and fetal circulation, amniotic fluid levels, and overall health. Drinking 2.5 L per day is appropriate and does not require intervention.

D. The client last visited the dentist 4 months ago: Regular dental care is encouraged, but a visit every 4–6 months is generally considered safe and routine. This finding does not indicate unsafe behavior requiring urgent evaluation.

A. "Supplement breastfeedings with water every 12 hours." B. "Limit the time your infant feeds to 10 minutes on each breast." C. "Begin each feeding using the same breast." D. "Offer your infant the breast when he shows signs of hunger."

Correct Answer is D

Explanation

Rationale:
A. "Supplement breastfeedings with water every 12 hours.": Breastfed infants do not require water supplementation because breast milk provides adequate hydration. Giving water can reduce milk intake, interfere with nutrition, and increase the risk of electrolyte imbalance.

B. "Limit the time your infant feeds to 10 minutes on each breast.": Feeding duration should be guided by the infant’s cues rather than a strict time limit. Limiting feeds can prevent the infant from receiving the hindmilk, which is richer in fat and essential for growth.

C. "Begin each feeding using the same breast.": Alternating the starting breast for each feeding helps ensure equal stimulation and milk production in both breasts. Starting with the same breast consistently may lead to uneven milk supply.

D. "Offer your infant the breast when he shows signs of hunger.": Responsive, cue-based feeding supports adequate nutrition, growth, and bonding. Feeding on demand—such as rooting, sucking on hands, or fussiness—helps establish and maintain milk supply and meets the infant’s needs effectively.

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A nurse is caring for a client who is 2 hr postoperative. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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