A nurse is caring for the client.
Select the 5 findings that indicate the client's condition has improved.
Heart rate
Temperature
Lochia
Hgb
WBC count
Fundal height
Correct Answer : A,B,C,E,F
A. Heart rate. The client’s heart rate decreased from 110/min on postpartum day 3 to 78/min on day 5, returning to normal resting range, which suggests improvement in systemic inflammation or infection, and better overall hemodynamic stability.
B. Temperature. The temperature has decreased from 38.6° C (101.5° F) to 37.1° C (98.9° F), which is within normal limits. This reduction is a key indicator of resolving infection or inflammation, especially considering the earlier febrile response.
C. Lochia. Lochia has improved from a moderate, foul-smelling, dark brown discharge to a small amount of brownish-red lochia with no odor, which suggests infection resolution and appropriate progression of postpartum uterine involution.
D. Hgb. The client’s hemoglobin dropped from 11.1 g/dL to 10 g/dL, which is below the normal postpartum range. This is likely due to ongoing recovery, recent surgery, and fluid shifts, but it does not indicate improvement and may require continued monitoring.
E. WBC count. The WBC count normalized from a significantly elevated 33,000/mm³ to 10,000/mm³, which is within the normal reference range. This is a strong sign that the infection or inflammatory response is resolving.
F. Fundal height. The fundus has decreased from 1 cm above the umbilicus on day 3 to 4 cm below on day 5, which is consistent with normal involution of the uterus during the postpartum period and is a positive sign of recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Revise the current policy for catheter care. Policy changes should be based on evidence and root cause analysis. Revising the policy prematurely without identifying contributing factors may not address the actual causes of infection.
B. Schedule nursing staff training for infection control procedures. Education and training are important but should be guided by identified gaps. Implementing training without understanding the root cause may result in ineffective interventions.
C. Meet with providers to discuss measures to decrease the infections. While interdisciplinary collaboration is valuable, it should occur after gathering and analyzing relevant data. This ensures targeted, evidence-based recommendations.
D. Identify possible precipitating factors related to the infections. The first step in quality improvement is to investigate and assess contributing factors. This helps guide the most appropriate and effective interventions to reduce infection rates.
Correct Answer is B
Explanation
A. The client calls the office multiple times per day to speak with their provider. This behavior may indicate anxiety or dependence, but it does not reflect rationalization, which involves making excuses to justify behavior.
B. The client states, "I only act this way because my partner makes me so angry." This is a clear example of rationalization, where the client is attempting to justify unacceptable behavior by blaming it on someone else rather than taking personal responsibility.
C. The client does not listen to the nurse during a discussion about their diagnosis. This may indicate denial or avoidance, not rationalization. The client may be overwhelmed and unwilling to accept the diagnosis.
D. The client reports that they get upset with their family members for "no apparent reason." This may suggest emotional dysregulation or projection, but it lacks the clear element of excuse-making that defines rationalization.
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