A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?
A client who reports luchia rubra requiring changing perineal pads every 3 hr
A client who has a urinary output of 300 mL in 8 hr
A client who is receiving magnesium sulphate and has absent deep tendon reflexes
A client who reports abdominal cramping during breastfeeding
The Correct Answer is C
A. A client who reports lochia rubra requiring changing perineal pads every 3 hr: Lochia rubra is the normal discharge during the early postpartum period. Changing perineal pads every 3 hours is within the expected range and does not warrant immediate notification of the provider.
B. A client who has a urinary output of 300 mL in 8 hr: Although the urinary output is relatively low, the information provided is not sufficient to conclude that this is abnormal. Further assessment is needed, and this finding alone may not be an emergency. However, it should be monitored.
C. A client who is receiving magnesium sulfate and has absent deep tendon reflexes: Absent deep tendon reflexes can be a sign of magnesium toxicity. Magnesium sulfate is used for various indications, such as preeclampsia or eclampsia, but it has a narrow therapeutic range. Absent deep tendon reflexes suggest the need for immediate attention and notification of the provider.
D. A client who reports abdominal cramping during breastfeeding: Abdominal cramping during breastfeeding is a common postpartum symptom associated with uterine contractions. It is a normal physiological response and does not require immediate notification of the provider.
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Related Questions
Correct Answer is D
Explanation
A. Administer 500 ml lactated Ringer's IV bolus:
This choice may be relevant in the context of postpartum hemorrhage, but the first step should be to assess the client's status, including urinary output. Administering fluids without a clear assessment may not address the underlying cause.
B. Replace the surgical dressing:
Vaginal bleeding after a cesarean birth is unlikely to be addressed by replacing the surgical dressing. This action may not address the root cause of the bleeding, which needs further assessment.
C. Apply an ice pack to the incision site:
Using an ice pack is not the appropriate intervention for postpartum bleeding. Ice is typically used for pain and swelling, not for controlling bleeding.
D. Evaluate urinary output:
This is the correct choice. Evaluating urinary output is crucial to assess the client's overall fluid status and kidney perfusion. In the context of postpartum bleeding, it helps determine if there is hypovolemia or other issues contributing to the bleeding. Adequate urinary output is a positive sign of organ perfusion.
Correct Answer is B
Explanation
A. I will receive a series of three immunizations, and each one will be a month apart: This statement is not accurate for rubella immunization. The MMR vaccine is usually administered as a single injection.
B. I should avoid becoming pregnant for at least 1 month following the immunization
Rubella immunization is typically administered as the measles, mumps, and rubella (MMR) vaccine. The statement indicating understanding reflects awareness of the importance of avoiding pregnancy for a certain period after receiving the rubella immunization due to potential risks to the developing fetus.
C. I should avoid breastfeeding for 2 weeks following the immunization: Breastfeeding is not a contraindication after receiving the rubella immunization. In fact, breastfeeding is generally not affected, and mothers can continue to breastfeed.
D. I will report joint pain that develops after the immunization to my provider immediately: Joint pain is a potential side effect of the rubella vaccine. Reporting joint pain to the provider is essential for monitoring and addressing any adverse reactions.
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