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A nurse on a postpartum unit is caring for a client.

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Vital Signs:

Postpartum day 3, 0815:

Temperature 38.2° C (100.8° F)

Heart rate 104/min

Respiratory rate 18/min

BP 108/70 mm Hg

SaO2 97% on room air

Nurses' Notes:

Postpartum day 3, 0815:

Client reports feeling unwell.

Lung sounds clear but diminished in the bases.

Client states breasts feel firm, heavy, and warm with moderate nipple discomfort while breastfeeding.

Uterus firm at 1 cm above the umbilicus and tender to palpation.

Fundus boggy but firmed with massage.

Moderate amount of dark brown, foul-smelling lochia noted.

Surgical incision well approximated with slight edema present; no redness or drainage noted.

No bowel movement since birth, hypoactive bowel sounds.

Diagnostic Results:

Postpartum day 3, 0900:

Hemoglobin 11.1 g/dL (greater than 11 g/dL)

WBC count 33,000/mm3 (5,000 to 10,000/mm)

Temperature 38.2° C (100.8° F)

Heart rate 104/min

BP 108/70 mm Hg

SaO2 97% on room air

Client reports feeling unwell

Client states breasts feel firm, heavy, and warm with moderate nipple discomfort while breastfeeding

Uterus firm at 1 cm above the umbilicus and tender to palpation

Moderate amount of dark brown, foul-smelling lochia noted

Surgical incision well approximated with slight edema present; no redness or drainage noted

WBC count 33,000/mm3 (5,000 to 10,000/mm)

Answer and Explanation

The Correct Answer is ["A","B","E","G","H","J"]

Rationale for correct choices

• Temperature 38.2° C (100.8° F): A temperature above 38° C after the first 24 hours postpartum is concerning for infection. This client has multiple risk factors including cesarean delivery and prolonged rupture of membranes. Fever in this patient warrants immediate evaluation for postpartum endometritis or mastitis.

• Heart rate 104/min: Tachycardia can indicate a systemic inflammatory or infectious process in the postpartum period. When paired with fever and uterine tenderness, it raises concern for sepsis or worsening uterine infection. Early recognition is critical to prevent complications.

• Client reports feeling unwell: A subjective report of feeling unwell is an important early sign of infection or systemic illness. This symptom, combined with abnormal vital signs and laboratory findings, suggests the client may be developing a postpartum complication requiring prompt intervention.

• Uterus firm at 1 cm above the umbilicus and tender to palpation: Uterine tenderness beyond the immediate postpartum period is abnormal and commonly associated with endometritis. The elevated fundal height also suggests delayed uterine involution, reinforcing concern for uterine infection.

• Moderate amount of dark brown, foul-smelling lochia: Foul-smelling lochia is a classic indicator of postpartum uterine infection. Normal lochia should not have an offensive odor, and this finding strongly supports suspected endometritis requiring immediate follow-up.

• WBC count 33,000/mm³: Although mild leukocytosis is expected postpartum, a WBC count this elevated exceeds normal physiologic changes. In the presence of fever and uterine findings, this level is highly suggestive of an acute infectious process.

Rationale for incorrect choices

• Breasts feel firm, heavy, and warm with moderate nipple discomfort: These findings are consistent with normal breast engorgement during early breastfeeding. While uncomfortable, they are expected postpartum changes and do not indicate infection in the absence of localized redness or systemic signs.

• Surgical incision well approximated with slight edema present: Mild edema without redness, drainage, or separation is a normal postoperative finding. There are no signs suggesting a surgical site infection at this time.

• Respiratory rate 18/min, BP 108/70 mm Hg, SaO₂ 97%: These vital signs fall within expected postpartum ranges and do not indicate acute instability. They do not contribute to the immediate concern for infection or deterioration.

Nursing Test Bank

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Correct Answer is A

Explanation

A. Critical pathways should reduce health care costs: Critical pathways are structured, multidisciplinary care plans designed to improve efficiency, standardize care, and optimize resource utilization. By promoting evidence-based practices and reducing unnecessary interventions, they help lower overall health care costs.

B. Critical pathways have an unlimited timeframe for completion: Critical pathways are time-specific and outline expected progress within defined periods. An unlimited timeframe would defeat the purpose of tracking efficiency and outcomes, which is central to their function.

C. Nurses' notes are used to create the critical pathway: Critical pathways are developed from evidence-based guidelines and multidisciplinary input, not solely from nurses’ documentation. While nurses contribute to care documentation, notes do not serve as the foundation for pathway creation.

D. Nurses should discontinue the critical pathway if variances occur: Variances from the expected pathway do not warrant discontinuation. Instead, variances are documented and analyzed to understand deviations, inform quality improvement, and guide individualized care adjustments.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

Rationale for correct choices

• Stop the magnesium sulfate infusion: The client exhibits signs of magnesium sulfate toxicity, including lethargy, shallow respirations, hyporeflexia (DTR 1+), and oliguria (urine output 20 mL/hr). Immediate cessation of the infusion is the priority to prevent progression to respiratory depression, coma, or cardiac arrest. Stopping the infusion reduces further magnesium accumulation and stabilizes the client.

• Calcium gluconate: Calcium gluconate is the antidote for magnesium sulfate toxicity. It counteracts the neuromuscular and cardiac effects of magnesium, reversing hyporeflexia and respiratory depression. The nurse should prepare calcium gluconate IV for rapid administration while monitoring vital signs and respiratory status closely.

Rationale for incorrect choices

• Apply oxygen via nasal cannula: Although supplemental oxygen can support the client’s respiratory function, it does not reverse the toxic effects of magnesium. Oxygen therapy alone is insufficient in managing magnesium toxicity and is secondary to stopping the infusion.

• Place the client in Trendelenburg position: Trendelenburg positioning is not indicated and may worsen respiratory compromise. Maintaining a side-lying or semi-Fowler’s position is safer for airway management and monitoring during magnesium toxicity.

• Magnesium sulfate: Continuing magnesium sulfate would worsen toxicity, potentially leading to respiratory failure, cardiac arrest, and further CNS depression. Administration is contraindicated once toxicity signs appear.

• IV antibiotics: There is no indication of infection or sepsis in the client’s current assessment. Antibiotics do not address magnesium toxicity and are not warranted at this stage.

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Assessment	Findings
Nurses' Notes	Client reports lower back pain as 0 on a scale from 0 to 10 No reports of vaginal discharge Membranes are intact. No uterine contractions noted. FHR baseline 138/min, minimal variability. No further reports of burning with urination.
Vital Signs	Temperature 37.1° C (98.7° F) Blood pressure 120/76 mm Hg
Laboratory Results	WBC count 12,000/mm3 (5,000 to 10,000/mm3) Platelet count 188,000/mm3 (150,000 to 400,000/mm)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse plan to include?

Correct Answer is A

Explanation

The nurse continues to care for the client who is at 30 weeks of gestation. Complete the following sentence by using the lists of options. Based on the client findings, the nurse should first _____ and then prepare to administer _____ .

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

A nurse is caring for a client who is obese. The client is crying and states, "Everyone is staring at me because of my weight." Which of the following responses should the nurse make?

A nurse is monitoring a client who is 36 hr postoperative following gastric banding. Which of the following findings should the nurse expect?

The nurse continues to care for the client who is at 30 weeks of gestation. Complete the following sentence by using the lists of options The client is at highest risk for developing _____ as evidenced by the client's _____ and _____

A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

A nurse in an urgent care clinic is caring for an infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect?

A nurse is caring for a client who is 24 hr postpartum and is breastfeeding her newborn. The client asks the nurse to warm up seaweed soup that the client's partner brought for her. Which of the following responses should the nurse make?

A nurse on a postpartum unit is caring for a client. Complete the following sentence by using the lists of options. The client is most likely experiencing _____ as evidenced by the client's _____ .