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 {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"}}
Explanation
Deep tendon patellar reflex (DTR): The client’s reflexes decreased from 4+ on Day 1 to 2+ on Day 2. Hyperactive reflexes are a hallmark of preeclampsia with severe features, so the reduction indicates an improvement in neuromuscular excitability.
Blood pressure: While slightly decreased from 166/110 mm Hg (Day 1, 0930) to 152/90 mm Hg (Day 2, 0900), indicating partial improvement with antihypertensive therapy. However, the BP remains elevated above normal range requiring further management.
Heart rate: The heart rate changed from 84–90/min (Day 1–Day 2), which is stable and within normal limits, suggesting no acute cardiovascular compromise.
Edema: The client continues to have +3 pitting edema in bilateral lower extremities on both Day 1 and Day 2, showing no change in fluid retention.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
Rationale:
Aspiration: The client has high gastric residual volumes (220 mL at 0800, 280 mL at 0900) while receiving enteral feedings via NG tube. Delayed gastric emptying increases the risk that stomach contents could reflux and enter the lungs, causing aspiration pneumonia. Continuous monitoring and potentially holding or adjusting feedings are indicated.
Skin breakdown: The client is postoperative, has an NG tube, limited mobility, and is experiencing pain that may reduce movement. These factors, combined with urine output changes and potential incontinence, increase the risk for pressure ulcers and skin breakdown at pressure points.
Other risks such as bleeding, hyperglycemia, and urinary retention are less immediate given the client’s current assessment and lab/vital signs.
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