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 C
Explanation
Rationale:
A. The client is doing 30 min of moderate exercise daily: Regular moderate exercise (e.g., walking, swimming) is recommended in pregnancy. It improves circulation, mood, and endurance for labor.
B. The client last visited the dentist 4 months ago: Dental care is encouraged during pregnancy because hormonal changes increase the risk of gingivitis. A dental visit 4 months ago is appropriate.
C. The client started working in a parking garage 3 months ago: Parking garages have poor ventilation and potential exposure to carbon monoxide (CO) from car exhaust, which can cause fetal hypoxia and developmental harm. The nurse should assess environmental safety and possibly recommend reassignment.
D. The client is drinking 2.5 L of water per day: Adequate hydration is essential in pregnancy to maintain amniotic fluid volume and prevent dehydration.
Correct Answer is ["B","C","E","F"]
Explanation
A. Sputum cultures are indicated for suspected respiratory infections, not myocardial infarction. This is incorrect.
B. A 12-lead ECG is the first diagnostic test for chest pain to identify ST-segment elevation or ischemic changes indicating myocardial infarction.
C. Antiplatelet therapy (e.g., aspirin) prevents further platelet aggregation and thrombus formation, which improves coronary blood flow during acute coronary syndromes.
D. ABGs may provide information about oxygenation, but are not routinely required unless severe respiratory compromise or acidosis is suspected. Priority is oxygen and cardiac assessment.
E. Preparing for cardiac catheterization (coronary angiography) is appropriate since this client shows positive troponins and unrelieved chest pain, indicating myocardial infarction requiring reperfusion evaluation.
F. Oxygen administration at 2 L/min via nasal cannula helps improve oxygenation (SpO₂ 89%) and reduces myocardial ischemia. Maintaining SpO₂ ≥ 90% is essential to minimize cardiac workload.
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