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","B","D","E","G"]
Explanation
Choice A rationale: The client’s temperature is 38.3°C (101°F), which is above the normal range (36.5-37.2°C or 97.7-99°F). This could indicate an infection, which is a common postpartum complication. Fever in the postpartum period can be due to endometritis, wound infection, mastitis, or urinary tract infection. Given the client’s report of a burning sensation during urination, a urinary tract infection could be a possibility. This finding requires immediate follow-up.
Choice B rationale: The client’s pulse rate is 110/min, which is above the normal range (60-100/min). This could indicate tachycardia, which can be a response to fever, pain, anxiety, or blood loss. Given the client’s elevated temperature and report of pain, this finding requires immediate follow-up.
Choice C rationale: The client’s respiratory rate is 22/min, which is within the normal range (12-20/min). While it’s slightly elevated, it’s not as concerning as the other findings. However, the nurse should continue to monitor the client’s respiratory rate along with other vital signs.
Choice D rationale: The client’s blood pressure is 140/90 mm Hg, which is higher than the normal range (90-120/60-80 mm Hg). This could indicate hypertension, which can be a complication in the postpartum period. Hypertension can lead to complications such as preeclampsia or eclampsia, which can be life-threatening. This finding requires immediate follow-up.
Choice E rationale: The client has a large amount of lochia rubra. Lochia rubra is normal for the first few days after delivery, but a large amount could indicate postpartum hemorrhage, especially if it’s accompanied by signs of hypovolemia such as tachycardia and hypotension. This finding requires immediate follow-up.
Choice F rationale: The client reports pain as 5 on a scale of 0 to 10. While pain is expected after a vaginal delivery, especially with an episiotomy, it should be manageable with analgesics. If the client’s pain is not well-controlled, it could indicate a complication such as infection or hematoma at the episiotomy site. However, given the information provided, this finding does not require immediate follow-up as much as the others.
Choice G rationale: The client has 3+ peripheral edema in bilateral lower extremities. While some edema is normal during pregnancy and the postpartum period, 3+ edema could indicate a complication such as deep vein thrombosis, especially if it’s accompanied by pain, warmth, or redness. This finding requires immediate follow-up.
Correct Answer is A
Explanation
Choice A rationale
Lentils are a great source of dietary fiber. A cup of cooked lentils contains approximately 15.6 grams of fiber, which is higher than the other options listed.
Choice B rationale
A cup of cooked oatmeal contains about 4 grams of fiber, which is less than lentils.
Choice C rationale
A cup of raw cabbage contains about 2.2 grams of fiber, which is less than lentils.
Choice D rationale
A cup of cooked asparagus contains about 3.7 grams of fiber, which is less than lentils.
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