A nurse is caring for a mother who delivered vaginally 2 hr ago.
Heart rate 106/min.
Axillary temperature 36.6° C (98.0° F). Respiratory rate 22 /min.
Oxygen saturation 94%. Select the 4 findings the nurse should report to the provider.
Respiratory assessment.
Hemoglobin level.
Heart rate.
Constant trickle of blood at vagina.
Correct Answer : A,B,C,D
Choice A rationale
Abnormal respiratory assessment findings, such as increased respiratory rate or difficulty breathing, could indicate respiratory distress or infection and should be reported to the provider for immediate evaluation.
Choice B rationale
Hemoglobin level is a critical indicator of blood loss and overall oxygen-carrying capacity. A low level postpartum could suggest significant blood loss or anemia and requires reporting.
Choice C rationale
A heart rate of 106/min is higher than normal and could indicate underlying issues such as pain, anxiety, or hemorrhage. It should be reported to the provider for further assessment.
Choice D rationale
A constant trickle of blood at the vagina could indicate ongoing bleeding from a laceration or retained placental fragments, requiring immediate attention and intervention by the provider. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Perineal care for a client who just transferred from labor and delivery is within the scope of practice for a certified nursing assistant (CNA). CNAs are trained to provide basic care, such as hygiene and assistance with activities of daily living, to postpartum clients.
Choice B rationale
Monitoring an area of redness on the incision of a Cesarean section client requires clinical assessment skills beyond the scope of a CNA. It involves evaluating the incision for signs of infection or other complications, which is the responsibility of a registered nurse.
Choice C rationale
Providing discharge instructions, such as using a sitz bath, requires teaching and evaluation skills. Registered nurses are responsible for providing education and ensuring client understanding before discharge.
Choice D rationale
Monitoring for signs of pre-eclampsia involves assessment and interpretation of symptoms such as blood pressure, edema, and proteinuria, which are beyond the scope of a CNA. This is a responsibility of a registered nurse.
Correct Answer is C
Explanation
Choice A rationale
A diaphragm must be left in place for at least 6 hours after intercourse to prevent sperm from reaching the uterus. This ensures effective contraception.
Choice B rationale
Depo-Provera is a long-acting contraceptive injection, and fertility can return within a few months after stopping, but it may take up to 9-10 months for some women to regain their regular menstrual cycles and fertility.
Choice C rationale
The Ortho Evra patch is a hormonal contraceptive that is applied weekly, not monthly. It needs to be replaced once a week for three weeks, followed by a patch-free week.
Choice D rationale
Male and female condoms should not be used together because they can create friction and cause either or both condoms to break or slip, reducing their effectiveness as contraceptives and increasing the risk of sexually transmitted infections.
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