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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
Correct Answer is B
Explanation
A. Plan to administer ephedrine IV: Ephedrine is a medication commonly used to treat hypotension. While addressing hypotension may be necessary in the management of AFE, the priority is to initiate immediate life-saving measures, such as CPR.
B. Prepare to initiate cardiopulmonary resuscitation: This is the correct answer. In the event of AFE, the client may experience sudden cardiovascular collapse and respiratory distress. Prompt initiation of CPR is crucial to support vital functions and improve the chances of survival.
C. Assist the client to empty their bladder: While assisting the client to empty the bladder is a routine measure, it is not the priority in the management of AFE. Immediate attention to the life-threatening complications is necessary.
D. Assess the presence of clonus: Clonus refers to a series of involuntary, rhythmic, muscular contractions and relaxations. While neurological signs may be assessed in the overall evaluation of a client, it is not the priority in the acute management of AFE.
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