A nurse is caring for a mother who delivered vaginally 2 hours ago.Select the 4 findings the nurse should report to the provider.
Fundus midline and firm at the umbilicus.
Moderate lochia rubra with no clots.
Constant trickle of blood at the vagina.
Hemoglobin level.
Heart rate.
Correct Answer : C,D,E
Choice A rationale
A fundus midline and firm at the umbilicus is a normal postpartum finding and does not require reporting. It indicates that the uterus is contracting as expected to prevent postpartum hemorrhage.
Choice B rationale
Moderate lochia rubra without clots is expected in the immediate postpartum period and does not need to be reported. It is part of normal postpartum bleeding as the uterus sheds its lining.
Choice C rationale
A constant trickle of blood at the vagina postpartum could indicate a laceration or retained placental fragments and should be reported to the provider for further evaluation and management.
Choice D rationale
Hemoglobin levels can provide important information about the mother's blood loss during delivery. A low hemoglobin level could indicate significant blood loss and necessitates reporting.
Choice E rationale
An abnormal heart rate in a postpartum mother could be indicative of complications such as hemorrhage or infection and should be reported to the provider for further assessment.
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
Anticonvulsants can induce liver enzymes, increasing the metabolism of combined oral contraceptives (COCs) and reducing their effectiveness.
Choice B rationale
Antihypertensives do not have a significant impact on the effectiveness of COCs.
Choice C rationale
Antioxidants do not interfere with the metabolism or effectiveness of COCs.
Choice D rationale
Antibiotics, except for rifampin, typically do not reduce the effectiveness of COCs.
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