A nurse is caring for a primiparous client in the postpartum unit. The client was induced at 41 weeks gestation with misoprostol and oxytocin and gave birth vaginally 4 days ago. She was discharged home on day two with her newborn and has been breastfeeding around the clock. She called her healthcare provider this morning with fatigue, new-onset headache, nausea, dizziness, weakness, and seeing "flashing lights."
Exhibits:
The nurse reviews the client's history, physical, and flow sheet to determine the cause of the client's symptoms. Highlight the information from the history, physical, and flow sheet that require further evaluation. Select all that apply.
Hemoglobin 10.4 g/dL (6.45 mmol/L)
Platelets 150,000/mm³ (150 x 10⁹/L)
New-onset headache
Vomiting small amount of yellow fluid
Right upper quadrant pain
Seeing flashing lights
Elevated blood pressure
Iron supplementation
Correct Answer : C,D,E,F,G
Choice A rationale: Hemoglobin of 10.4 g/dL is slightly below the normal range for non-pregnant women (12-16 g/dL) but may be acceptable postpartum. Mild anemia can cause fatigue but doesn't explain the new-onset headache, dizziness, or elevated blood pressure.
Choice B rationale: Platelet count of 150,000/mm³ is within the normal range (150,000-450,000/mm³). Thrombocytopenia would be a concern if platelets were below 150,000/mm³, as it can cause bleeding, but it doesn't correlate with the client's symptoms.
Choice C rationale: New-onset headache, especially unrelieved by ibuprofen, is concerning. Postpartum preeclampsia can present with a severe headache. The headache, combined with elevated blood pressure, requires further investigation for potential complications like cerebral edema or hypertensive encephalopathy.
Choice D rationale: Vomiting yellow fluid may indicate gastrointestinal distress or bile. In the context of right upper quadrant pain and elevated blood pressure, it raises concerns for conditions like HELLP syndrome or liver involvement. Further evaluation is needed to rule out these possibilities.
Choice E rationale: Right upper quadrant pain can be a symptom of postpartum preeclampsia or HELLP syndrome, where liver enzymes are elevated. Pain in this area combined with other symptoms like headache, nausea, and elevated blood pressure warrants further investigation.
Choice F rationale: Seeing flashing lights is a potential sign of visual disturbances related to severe hypertension or preeclampsia. It can be an indication of impending eclampsia or other complications like retinal detachment or cerebral edema. This symptom must be promptly evaluated.
Choice G rationale: Elevated blood pressure (169/104 mm Hg) is a critical finding. Normal postpartum blood pressure should be below 140/90 mm Hg. Severe hypertension postpartum can lead to complications like preeclampsia, eclampsia, or stroke. Immediate medical evaluation is required.
Choice H rationale: Iron supplementation is common postpartum to address mild anemia and restore iron levels depleted during pregnancy and delivery. While important for recovery, it does not explain the new-onset headache, elevated blood pressure, or other symptoms reported by the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Monitoring for respiratory distress and checking oxygenation by pulse oximetry are critical in newborns, as they can indicate hypoxemia or respiratory issues requiring prompt intervention.
Choice B rationale
Maintaining the infant's temperature at 97.6°F (36.4°C) using a warmer and bilirubin lights is essential for thermoregulation and treating jaundice, ensuring proper physiological stability.
Choice C rationale
Regular temperature monitoring is vital to detect any signs of hypothermia or hyperthermia, which can indicate underlying health issues and guide appropriate interventions for the newborn.
Choice D rationale
Continued monitoring of glucose levels is crucial for detecting hypoglycemia, a common condition in newborns that can lead to seizures, brain damage, or other severe complications if left untreated.
Correct Answer is D
Explanation
Choice A rationale
Asking another nurse to validate the costal angle finding is unnecessary, as the increased costal angle is a common physiological change during pregnancy due to the expanding uterus.
Choice B rationale
Examining for tissue anoxia, such as pallor, is not relevant in this scenario, as the nasal stuffiness and nosebleeds are likely due to increased blood volume and hormonal changes in pregnancy.
Choice C rationale
Requesting the healthcare provider to evaluate the client's respiratory status is unwarranted, as the described symptoms are typical physiological adaptations during pregnancy and not indicative of respiratory pathology.
Choice D rationale
Documenting the respiratory finding as normal is appropriate, as the increased chest circumference, thoracic breathing, elevated diaphragm, and increased costal angle are expected physiological changes during pregnancy.
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