A nurse working on a postpartum unit is collecting data from four clients. Which of the following findings should the nurse report to the provider?
A client who has a reddened area on their right calf
A client who reports painful uterine contractions during breastfeeding
A client who has a urinary output of 125 mL in 4 hr
A client who reports changing their perineal pad every 2 hr
The Correct Answer is C
A) Incorrect- A reddened area on the calf might indicate a potential blood clot (deep vein thrombosis), which is important to assess but may not be the highest priority.
B) Incorrect- Painful uterine contractions during breastfeeding can be a normal response due to oxytocin release during breastfeeding and might not require immediate reporting.
C) Correct - A urinary output of 125 mL in 4 hours is significantly low and could indicate inadequate fluid intake, potential urinary retention, or other issues that need prompt attention. It is a sign of impaired renal function. This could indicate dehydration, blood loss, infection, or kidney injury. The nurse should assess the client's fluid intake and output, vital signs, urine specific gravity, and serum electrolyte levels. The nurse should also monitor the client for signs of hypovolemia, such as tachycardia, hypotension, and decreased skin turgor.
D) Incorrect- Changing a perineal pad every 2 hours is within the normal range for postpartum bleeding and might not require immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect- Taking the medication with breakfast may not ensure optimal absorption of iron, especially if the breakfast does not include a vitamin C source.
B) Incorrect- Taking the medication with the midday meal is not the best option for enhancing iron absorption.
C) Correct - Taking the medication with a glass of orange juice provides a source of vitamin C, which can improve iron absorption.
D) Incorrect- Taking the medication with milk is not recommended, as calcium in milk can interfere with iron absorption.
Correct Answer is C
Explanation
A. Elevated blood pressure is typically associated with gestational hypertension or preeclampsia rather than hyperemesis gravidarum. In hyperemesis, the significant fluid loss through protracted vomiting more commonly leads to hypovolemia and a subsequent decrease in systemic blood pressure. While compensatory tachycardia may occur, hypertension is not a direct scientific expectation for this clinical condition.
B. Leukopenia, which is a decrease in the white blood cell count, is not a typical finding in clients suffering from hyperemesis gravidarum. Hemoconcentration caused by severe dehydration may actually result in a relative increase in various laboratory values, including hematocrit and occasionally white cell counts. There is no physiological mechanism within this disorder that causes the bone marrow suppression required for leukopenia.
C. Hydramnios, or excessive amniotic fluid volume, is generally associated with fetal anomalies or maternal diabetes rather than severe vomiting. Hyperemesis gravidarum is characterized by a state of maternal fluid volume deficit rather than an excess of amniotic fluid. In severe, untreated cases, maternal dehydration might actually lead to decreased placental perfusion and a potential reduction in amniotic fluid.
D. Ketonuria is a critical finding in hyperemesis gravidarum that indicates the body has shifted to an anaerobic metabolic state. Because the client cannot retain sufficient carbohydrates for energy, the body begins catabolizing adipose tissue to produce fuel, resulting in the accumulation of ketone bodies. The presence of these ketones in the urine confirms that the client is experiencing metabolic starvation and requires immediate intervention.
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