A nurse is caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?

Explanation

Choice A Reason:

A heart rate of 89 beats per minute is within the normal range for a postpartum client and does not typically require immediate intervention. However, the nurse should continue to monitor the client's vital signs for any significant changes.

Choice B Reason:

Blood pressure of 120/70 mm Hg is within the normal range for a postpartum client and does not typically require immediate intervention. However, as with other vital signs, ongoing monitoring is essential.

Choice C Reason:

Cool, clammy skin can be indicative of hypovolemia or shock, which can occur postpartum due to excessive bleeding (hemorrhage) or other complications. Therefore, this finding should be reported to the provider promptly for further evaluation and intervention to prevent potential complications.

Choice D Reason:

Moderate lochia serosa is incorrect. Lochia serosa, which is the pinkish-brown vaginal dis charge occurring 3 to 10 days postpartum, is considered normal. Moderate lochia serosa is also within the expected range for this stage of postpartum recovery and does not require immediate intervention. However, if lochia becomes excessive, foul-smelling, or accompanied by signs of infection, it should be reported to the provider for further evaluation.

Explanation

Choice A Reason:

"Have you noticed any swelling in your feet?" This question is inappropriate. Swelling in the feet is not directly related to postoperative pain following a cesarean birth. While swelling may indicate other issues such as fluid retention, it is not typically a primary indicator of pain requiring PRN pain medication.

Choice B Reason:

"Do you have any leakage from your incision?" This question is inappropriate. Leakage from the incision may indicate wound complications such as infection or dehiscence, but it does not specifically assess pain. PRN pain medication would be indicated based on the client's reported pain level, rather than the presence of incisional leakage alone.

Choice C Reason:

"Do you notice increased cramping with breastfeeding?" This question is appropriate. After a cesarean birth, it is common for women to experience cramping, especially during breastfeeding. This is due to the release of oxytocin, a hormone that helps the uterus contract back to its pre-pregnancy size. Increased cramping with breastfeeding can exacerbate postoperative pain in women who have undergone a cesarean birth. Therefore, asking about increased cramping with breastfeeding is an important question to assess pain and determine if additional pain medication is needed.

Choice D Reason:

"Are you able to pass gas?" This question is inappropriate. Passing gas is an important aspect of gastrointestinal function but is not directly related to postoperative pain following a cesarean birth. While constipation and gastrointestinal issues can contribute to discomfort, asking about the ability to pass gas does not specifically assess pain or indicate the need for PRN pain medication.