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 B
Explanation
A. The client cleans the perineum with a squeeze bottle after urinating: This action is appropriate for postpartum perineal care. Using a squeeze bottle to cleanse the perineum with warm water after urination helps maintain cleanliness without causing trauma to the area.
B. The client is changing the perineal pad once daily: Changing the perineal pad once daily is not optimal for wound healing. Postpartum perineal wounds require frequent changing of pads to maintain cleanliness, prevent infection, and promote healing.
C. The client is using witch hazel pads on the perineum: Using witch hazel pads is a common practice for postpartum perineal care. Witch hazel has a soothing effect and can help reduce inflammation and discomfort without negatively affecting wound healing.
D. The client's perineal suture line is well-approximated: A well-approximated perineal suture line is a positive finding, indicating that the edges of the wound are properly aligned and closed, which supports the healing process.
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Explanation
For the findings 24 hours later, the nurse should interpret them as follows:
Urinary output: 40 ml/hr
Interpretation: Sign of potential worsening condition
Explanation: A urinary output of 40 ml/hr is concerning and indicates potential dehydration. It is a sign of potential worsening of the client's condition, as it suggests inadequate fluid intake or ongoing fluid losses.
3+ ketones
Interpretation: Sign of potential worsening condition
Explanation: The presence of 3+ ketones in the urine suggests ongoing ketosis, which can occur in hyperemesis gravidarum due to starvation and the breakdown of fats for energy. It is a sign of potential worsening of the client's nutritional status.
Heart rate: 100/min
Interpretation: Sign of potential improvement
Explanation: A heart rate of 100/min is within the normal range. It can be interpreted as a sign of potential improvement, indicating that the client's cardiovascular system is maintaining an appropriate heart rate.
WBC count: 10,000/mm3
Interpretation: Unrelated to diagnosis
Explanation: The WBC count within the normal range (10,000/mm3) is unrelated to the diagnosis of hyperemesis gravidarum. It does not provide specific information about the client's condition in this context.
Urine specific gravity: 1.050
Interpretation: Sign of potential worsening condition
Explanation: A urine specific gravity of 1.050 is elevated and indicates concentrated urine. This finding is a sign of potential worsening of the client's dehydration status.
Urine pH: 5
Interpretation: Unrelated to diagnosis
Explanation: The urine pH of 5 is within the normal range and is unrelated to the diagnosis of hyperemesis gravidarum. It does not provide specific information about the client's condition in this context.
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