A nurse on the postpartum unit is caring for four patients.
For which of the following patients should the nurse notify the provider?
Patient who has a urinary output of 300 ml in 8 hours
Patient who reports lochia rubra requiring changing perineal pads every 3 hours
Patient who is receiving magnesium sulfate and has absent deep tendon reflexes
Patient who reports abdominal cramping during breastfeeding
The Correct Answer is C
Choice A rationale
A urinary output of 300 ml in 8 hours is within the normal range for a postpartum patient. The average urinary output is about 30 ml/hour.
Choice B rationale
Lochia rubra is a normal finding in the immediate postpartum period. It is the initial vaginal discharge after childbirth, which is red because it contains a large amount of blood. Changing perineal pads every 3 hours is considered normal.
Choice C rationale
A patient who is receiving magnesium sulfate and has absent deep tendon reflexes is experiencing magnesium toxicity. This is a serious condition that can lead to respiratory depression and cardiac arrest. The healthcare provider should be notified immediately.
Choice D rationale
Abdominal cramping during breastfeeding is a normal finding. During breastfeeding, the hormone oxytocin is released which can cause uterine contractions and lead to cramping.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The therapeutic effect of IV oxytocin administration following expulsion of the placenta is a firm and midline fundus. Oxytocin stimulates uterine contractions, which helps the uterus return to its pre-pregnancy size and position.
Choice B rationale
Saturating a perineal pad in 1 hr is not a therapeutic effect of oxytocin. This could be a sign of postpartum hemorrhage.
Choice C rationale
A feeling of vaginal fullness is not a therapeutic effect of oxytocin. This could be a sign of a vaginal hematoma.
Choice D rationale
The client’s umbilical cord lengthening is not a therapeutic effect of oxytocin. This could be a sign of placental separation.
Correct Answer is B
Explanation
Choice A rationale
Asking why the adolescent is requesting birth control may come across as judgmental and could discourage open communication.
Choice B rationale
Understanding what the adolescent knows about contraception can help guide the discussion and ensure that she is making an informed decision.
Choice C rationale
Whether or not the partner loves the adolescent is not directly relevant to the decision to use birth control. The focus should be on the adolescent’s reproductive health and autonomy.
Choice D rationale
While it’s important to discuss coercion in sexual relationships, this question could be seen as intrusive or presumptive. It’s more appropriate to provide information about healthy relationships and consent.
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