A nurse on a postpartum unit is caring for a client.
Heart rate
Temperature
Fundal height
WBC count
Lochia
Hgb
Correct Answer : A,B,C,D,E
Rationale:
A. Heart rate decreased from 110/min on day 3 to 78/min on day 5. Tachycardia is a common response to fever and infection. The return to normal heart rate indicates resolution of infection and improved systemic status.
B. Temperature decreased from 38.6°C (101.5°F) to 37.1°C (98.9°F). Afebrile status reflects infection resolution and successful antibiotic response.
C. Fundus descended from 1 cm above umbilicus (day 3) to 4 cm below umbilicus (day 5). Normal uterine involution should occur at about 1 cm/day; this finding confirms proper healing and uterine contraction.
D. WBC count decreased from 33,000/mm³ to 10,000/mm³, which is within the normal range (5,000–10,000/mm³). This indicates infection control and resolution of systemic inflammation.
E. Lochia changed from dark brown and foul-smelling to small amount of brownish-red lochia without odor. The progression and normalization of lochia color and odor indicate healing and resolution of uterine infection.
F. Hemoglobin (Hgb) decreased from 11.1 g/dL to 10 g/dL, indicating continued mild anemia likely related to blood loss from delivery or infection recovery. Although the drop is slight, it does not indicate clinical improvement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Assessing pressure points every 24 hours is insufficient. Skin should be assessed at least every shift or more often for high-risk clients.
B. Shifting weight every 15 minutes while sitting helps relieve pressure and improve circulation, preventing further skin breakdown. This is essential for clients with paraplegia who are at high risk for pressure injuries.
C. Turning every 3 hours is inadequate; repositioning should occur at least every 2 hours to prevent tissue ischemia.
D. Donut-shaped cushions are not recommended because they concentrate pressure around the edges, worsening tissue damage.
Correct Answer is D
Explanation
A. “Client in room 302 has had high blood glucose levels.” This statement lacks specific data (values, trends, or interventions) and is too vague to be useful.
B. “Client in room 304 is here because they are seeking narcotics.” This is a judgmental and non-objective statement, violating professional communication standards.
C. "Client in room 303 takes too many medications for their condition." This is subjective and unprofessional; only factual data should be reported.
D. “Client in room 301 is in the cardiac catheterization laboratory.” Objective, relevant information about the client’s current location, procedures, and treatments should be included in a shift report to ensure continuity of care.
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