A nurse is caring for a mother who delivered vaginally 2 hours ago.
Hemoglobin: 9 g/dL (11 to 14 g/dL). Hematocrit: 30% (36 to 43%). Platelets: 220,000/mm³ (150,000 to 400,000/mm³). WBC count: 12,000/mm³ (4,000 to 15,000/mm³). Temperature: 38.3°C (100.9°F). Select the 4 findings the nurse should report to the provider.
Respiratory assessment.
Hemoglobin level.
Heart rate.
Constant trickle of blood at the vagina.
Correct Answer : B,D
Choice A rationale
Respiratory assessment is important but not immediately concerning without specific abnormal findings.
Choice B rationale
Hemoglobin level of 9 g/dL is low and could indicate postpartum hemorrhage or anemia, warranting attention.
Choice C rationale
Heart rate abnormalities would be significant but are not provided in the data given.
Choice D rationale
Constant trickle of blood at the vagina suggests ongoing bleeding which could indicate a postpartum hemorrhage, requiring prompt intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Unstable vital signs in a newborn could be attributed to various causes such as infection, respiratory issues, or cardiovascular problems. It is not directly linked to the absence of phytonadione injection.
Choice B rationale
Low glucose levels in a newborn can result from conditions like prematurity, maternal diabetes, or feeding issues and are not a direct consequence of the absence of a phytonadione injection.
Choice C rationale
Acrocyanosis, a bluish discoloration of the hands and feet, is a common and benign finding in newborns due to immature blood circulation and is not related to the absence of phytonadione.
Choice D rationale
Phytonadione (vitamin K) is essential for blood clotting. Absence of this injection can lead to bleeding issues, such as oozing at circumcision sites, due to vitamin K deficiency bleeding (VKDB).
Correct Answer is A
Explanation
Choice A rationale
Antibiotics should be taken for the full prescribed course, typically 10-14 days, to ensure complete resolution of the infection. Stopping antibiotics early can lead to recurrence or resistance.
Choice B rationale
Continuing to breastfeed while having mastitis is encouraged as it helps keep milk flowing and prevents blockage.
Choice C rationale
Taking analgesics for pain relief is appropriate during mastitis as it helps manage discomfort and supports continued breastfeeding.
Choice D rationale
Wearing a supportive bra helps alleviate discomfort and supports the breasts, which is beneficial during mastitis.
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