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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "You can bathe and dress your baby if you'd like to": This statement acknowledges the client's autonomy and offers a sensitive and supportive approach. Allowing the client the option to participate in the care of the baby, such as bathing and dressing, respects the individual grieving process.
B. "I'm sure you will be able to have another baby when you’re ready": While the nurse may want to provide hope for the future, this statement might be perceived as minimizing the client's current grief and loss. It's essential to focus on the present and the client's emotions.
C. "You should name the baby so she can have an identity": Naming the baby is a personal choice, and the nurse should avoid directing the client on what they "should" do. Naming the baby can be a meaningful way for some parents to acknowledge the baby's existence and create memories.
D. "If you don’t hold the baby, it will make letting go much harder": Pressuring the client to hold the baby may not be appropriate, as individuals have different coping mechanisms. Some may find comfort in holding and spending time with the baby, while others may need more time before they are ready.
Correct Answer is D
Explanation
A. Report of perineal pain as 0 on a scale of 0 to 10: Perineal pain is more directly related to the effects of spinal anesthesia rather than fluid status. A decrease in perineal pain would be expected after the administration of spinal anesthesia, but it may not specifically indicate the effectiveness of the IV bolus.
B. Report of relief of pruritus: Pruritus (itching) is a common side effect of spinal anesthesia. Relief of pruritus can be expected after the administration of spinal anesthesia, but it is not a direct indicator of the effectiveness of the IV bolus.
C. Increased urinary output: Increased urinary output may indicate improved renal perfusion or fluid balance but is not a specific indicator of the effectiveness of the IV bolus in the context of spinal anesthesia for labor.
D. Blood pressure 110/70 mm Hg: This is the correct answer. Blood pressure is an important parameter to monitor, especially after administering an IV bolus of fluids. A blood pressure within the normal range (110/70 mm Hg) suggests that the bolus has been effective in addressing any hypovolemia or dehydration.
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