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 B
Explanation
Choice A rationale
While blood in the stool can be a sign of a problem in older children and adults, it is not uncommon for newborns to pass dark green or black stools (known as meconium) in the first few days after birth. This does not typically indicate a problem.
Choice B rationale
A newborn vomiting eight to ten times per day is a cause for concern. This could indicate a problem such as pyloric stenosis or gastroesophageal reflux disease, both of which require medical attention.
Choice C rationale
Cooling after each breastfeeding is not typically a sign of a problem. Newborns have immature temperature regulation systems, so slight variations in body temperature can occur.
Choice D rationale
Persistent crossing of the eyes in a newborn can be normal up to about 3 months of age. If it continues beyond this point, it may indicate a problem such as strabismus.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"}}
Explanation
- Urine pH 5.0: This is an improvement as the pH has increased from 4.4, moving closer to the normal range (4.6 to 8).
- Urine specific gravity 1.050: This is a sign of potential worsening as the specific gravity has increased from 1.040, indicating possible dehydration.
- 3+ ketones: This is a sign of potential worsening as the presence of ketones has increased from 2+, indicating the body is breaking down fat for energy due to insufficient glucose.
- Urinary output 40 mL/hr: This is an improvement as the urinary output has increased from 20 mL/hr, indicating better hydration.
- Heart rate 130/min: This is a sign of potential worsening as the heart rate has increased from 128/min, possibly due to dehydration.
- WBC count 10,000/mmt: This is unrelated to the diagnosis as it’s within the normal range (5,000 to 10,000/mm³) and doesn’t directly relate to the client’s symptoms of vomiting and dehydration.
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