A nurse is caring for a client who is 24 hr postpartum. Which of the following findings should the nurse report to the provider?
WBC count 12,000/mm3 (5,000 to 10,000/mm3)
Temperature 37.8° C (100° F)
Respiratory rate 16/min
Hgb 8 g/dL (less than 11 g/dL)
The Correct Answer is D
A. WBC count 12,000/mm³: A mild elevation in white blood cell count is expected within the first few days postpartum as part of the normal inflammatory response due to the stress of labor and delivery.. A count of 12,000/mm³ is not alarming and does not necessarily indicate infection or a complication.
B. Temperature 37.8°C (100°F): A low-grade temperature elevation within the first 24 hours postpartum is common due to hormonal shifts, dehydration, or exertion from labor. This finding would not immediately require provider notification unless it persists or rises higher.
C. Respiratory rate 16/min: A respiratory rate of 16 breaths per minute is within normal adult limits and does not suggest respiratory distress or any postpartum complication, so no intervention is required for this finding.
D. Hgb 8 g/dL: A hemoglobin level of 8 g/dL is significantly low and can indicate postpartum hemorrhage or significant blood loss. This degree of anemia should be reported promptly to the provider to assess the need for interventions such as blood transfusion or iron supplementation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Disposes of contaminated sheets in a linen bag: Contaminated linens should be placed in a designated leak-proof bag, often specifically marked for contaminated items. Simply disposing of them in a regular linen bag without proper precautions could lead to the spread of infection.
B. Wears clean gloves when performing oral hygiene: Wearing clean gloves during oral care is an effective and appropriate use of supplies to maintain standard precautions and protect both the client and the caregiver from potential contamination.
C. Empties the sharps container when it is full: The sharps container should be emptied when it is three-quarters full, not completely full. Waiting until it is full increases the risk of needlestick injuries and improper disposal practices.
D. Wears an N95 mask when bathing a client who has Clostridium difficile: For Clostridium difficile, the appropriate personal protective equipment includes gloves and a gown, not an N95 mask. C. difficile is transmitted via contact with spores, not through airborne particles.
Correct Answer is B
Explanation
A. Anorexia: Anorexia, or loss of appetite, is not a typical adverse effect directly associated with heparin use. While it may occur due to general postoperative factors, it is not an urgent or life-threatening reaction that necessitates immediate reporting related to anticoagulant therapy.
B. Epistaxis: Epistaxis, or nosebleed, is a sign of potential bleeding complications, which is a major adverse effect of heparin. Because heparin inhibits clot formation, any evidence of spontaneous bleeding must be reported immediately to the provider to assess for potential heparin-induced bleeding disorders.
C. Weight gain: Weight gain could suggest fluid retention, but it is not a typical adverse effect of heparin. While postoperative clients should be monitored for signs of fluid imbalance, sudden bleeding signs like epistaxis are far more critical to recognize and report when administering anticoagulants.
D. Bradycardia: Bradycardia, or slow heart rate, is not commonly linked to heparin therapy. While abnormal heart rhythms may occur postoperatively for other reasons, they are not typically associated with bleeding risks from heparin and thus do not require urgent reporting specific to heparin use.
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