A nurse on a postpartum caring for a client.
For each potential client finding, click to specify if the finding is expected or unexpected.
White blood cell count
Blood clot size
Uterine findings
Lochia findings
Calf findings
Blood pressure
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"}}
Client Finding Assessment:
White blood cell count (18,000/mm³)
Expected: An elevated white blood cell count is common postpartum due to the body's inflammatory response to delivery, especially within the first few days after birth. This level is within the typical postpartum range of 5,000 to 30,000/mm³.
Blood clot size (pea-sized)
Expected: Small blood clots are common during the early postpartum period. It is normal to see some small clots in the lochia as the uterus contracts and expels blood from the uterine lining.
Uterine findings (firm and midline, 1–2 cm below the umbilicus)
Expected: A firm, midline uterus with a descent of about 1–2 cm below the umbilicus is a normal finding during the early postpartum period. This indicates appropriate uterine involution.
Lochia findings (moderate to light amount, no odor, with clots)
Expected: Lochia rubra (red blood flow) is expected during the first few days postpartum, with moderate bleeding and the presence of small clots. The absence of foul odor suggests no infection, which is a positive sign.
Calf findings (one varicose vein visible on left calf)
Expected: It is common for women to have visible varicose veins during pregnancy due to increased blood volume and pressure on the veins. These may persist postpartum, and unless associated with pain or swelling, they do not typically require intervention.
Blood pressure (145/98 mm Hg)
Unexpected: Elevated blood pressure postpartum is concerning and could indicate postpartum hypertension or preeclampsia. This needs to be addressed and monitored closely as it can be a sign of a serious condition that requires further evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) The client will progress one station every 2 hours:
This statement is inaccurate. The progress of labor in terms of fetal station does not follow a predictable or uniform rate. While some progression might occur every hour or two, it varies greatly depending on factors such as the position of the fetus, maternal anatomy, and strength of contractions. Labor can progress at different rates, and not all clients will experience consistent progression every 2 hours.
B) The client should feel the urge to push at -2 station:
This statement is incorrect. The urge to push generally occurs once the fetal head has descended to +1 or +2 station, which is closer to the perineum. At -2 station, the fetal head is still relatively high in the pelvis, and the client typically will not feel the urge to push until the head is lower. The urge to push is often experienced when the fetal head is well engaged in the pelvis and ready for delivery.
C) The client's temperature will need to be checked every hour when the membranes have ruptured:
This statement is correct. Once the membranes have ruptured, there is an increased risk of infection, as the protective barrier of the amniotic sac is no longer intact. Checking the maternal temperature every hour is an essential practice to monitor for signs of infection, such as chorioamnionitis, especially since the longer the rupture lasts, the greater the risk of infection. A rise in temperature is a key indicator of infection in the postpartum period.
D) The client's cervix will need to be checked every 30 minutes:
This is not correct practice. Cervical checks should be performed only when clinically indicated, not routinely every 30 minutes. Frequent cervical checks can increase the risk of infection, especially after the membranes have ruptured. The cervix should be assessed when there is a clinical reason to do so, such as checking for progress in labor or when considering interventions like an epidural or pushing.
Correct Answer is ["5"]
Explanation
Given:
Desired dose: Digoxin 0.25 mg PO daily
Available concentration: Digoxin 500 mcg/10 mL
To find:
Volume to administer (in mL)
Step 1: Convert desired dose to micrograms
We know that 1 milligram (mg) is equal to 1000 micrograms (mcg). Therefore, to convert the desired dose from mg to mcg, we multiply by 1000:
Desired dose (mcg) = Desired dose (mg)x 1000
Desired dose (mcg) = 0.25 mg x 1000 = 250 mcg
Step 2: Set up the proportion
We can use the following proportion to solve the problem:
(Desired dose) / (Available concentration) = Volume to administer
Step 3: Substitute the values
Plugging in the given values, we get:
(250 mcg) / (500 mcg/10 mL) = Volume to administer
Step 4: Simplify
To simplify, we can invert the denominator and multiply:
(250 mcg) x (10 mL / 500 mcg) = Volume to administer
The "mcg" units cancel out, leaving us with:
(250 x 10 mL) / 500 = Volume to administer
Step 5: Calculate
Performing the multiplication and division, we get:
2500/ 500 = Volume to administer
5 mL = Volume to administer
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