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 A
Explanation
A. Smoking in bed: Smoking in bed is a major fire hazard and one of the leading causes of residential fires. Falling asleep with a lit cigarette can easily ignite bedding, mattresses, or upholstered furniture, leading to fast-spreading, deadly fires. This behavior significantly increases the risk of injury or death from residential fires.
B. Leaving the stove on: Leaving the stove unattended can also cause kitchen fires, but cooking-related incidents typically lead to localized fires rather than being the top cause of overall residential fires. Proper supervision while cooking is important, but smoking in bed remains a more dangerous, widespread cause of fatal home fires.
C. Lack of smoke detectors: Lack of smoke detectors does not cause fires but delays detection, increasing the risk of injury or death once a fire has already started. While smoke detectors are crucial for early warning and safety, they are not an ignition source that directly leads to the start of residential fires.
D. Placing a space heater 5ft from bed: Placing a space heater 5 feet away from a bed is generally considered safe, as heaters need clearance but are unlikely to cause fires at that distance. Improper use of space heaters can be hazardous, but when correctly placed, they are not the primary cause of residential fires compared to smoking in bed.
Correct Answer is A
Explanation
A. Powered-standing assist lift: A powered-standing assist lift is appropriate for a cooperative client with upper body strength who is non-weight bearing. It allows the client to participate by supporting themselves with their arms while the device safely moves them from the bed to a chair without bearing weight on their lower extremities.
B. Draw sheet: A draw sheet is typically used for repositioning a client in bed, not for transferring them from bed to chair. It does not provide the mechanical support needed to lift and transfer a non-weight-bearing client safely.
C. Gait belt: A gait belt is useful for clients who can bear weight to some degree and require minimal assistance during transfers. Since this client is non-weight-bearing, a gait belt alone would not provide adequate support and could lead to injury.
D. Full body sling lift: A full body sling lift is used for clients who are non-weight bearing and lack the ability to assist in transfers. Since the client described here is cooperative and has upper body strength, a full sling would not be necessary and may restrict their participation.
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