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 F
Explanation
Choice A rationale
Abnormal stool patterns can be a sign of various issues in newborns, but they do not align with the vital signs presented. The vital signs suggest a more systemic issue rather than one isolated to digestive patterns.
Choice B rationale
While temperature regulation is critical in newborns, especially those who are preterm, the vital signs presented suggest a broader systemic issue. The symptoms do not align with isolated temperature dysregulation.
Choice C rationale
Feeding difficulties can be a sign of neonatal abstinence syndrome but are not directly reflected in the vital signs presented. Neonatal Abstinence Syndrome (NAS) encompasses a range of withdrawal symptoms due to exposure to drugs in utero, not just feeding issues.
Choice D rationale
While extremity issues can be present in various neonatal conditions, they do not align with the systemic symptoms shown in the vital signs. NAS impacts multiple body systems and would present more generalized symptoms.
Choice E rationale
Hypoglycemia can present with some of these vital signs, such as a rapid heart rate, but it does not explain all the symptoms like increased respiratory rate and temperature dysregulation. It is a condition that requires monitoring but is not the primary diagnosis suggested here.
Choice F rationale
Neonatal Abstinence Syndrome is consistent with the vital signs: elevated heart rate, increased respiratory rate, and lower temperature. NAS results from withdrawal from substances the newborn was exposed to in utero and affects multiple body systems, explaining the range of symptoms.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale: Initiating phototherapy is essential for treating neonatal jaundice. Phototherapy helps to break down bilirubin in the skin, reducing serum bilirubin levels and preventing complications such as kernicterus. It is a common and effective treatment for elevated bilirubin levels in newborns.
Choice B rationale: Administering intravenous dextrose addresses the newborn's low blood glucose level. Hypoglycemia in newborns can lead to severe neurological complications if not treated promptly. Dextrose administration helps stabilize blood glucose levels, improving the newborn's overall condition.
Choice C rationale: Performing a lumbar puncture is not indicated in this scenario. The newborn's symptoms and diagnostic results do not suggest a need for this procedure. Lumbar punctures are typically performed to diagnose conditions such as meningitis, which is not evident here.
Choice D rationale: Encouraging frequent breastfeeding or formula feeding helps in reducing bilirubin levels and maintaining blood glucose levels. Adequate feeding promotes regular bowel movements, aiding in the excretion of bilirubin, and ensures the newborn receives necessary nutrients to stabilize blood glucose levels.
Choice E rationale: Administering naloxone is used for opioid withdrawal, which is not relevant in this case. The newborn's symptoms do not indicate opioid exposure, so this intervention is unnecessary.
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