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 ["A","B","E"]
Explanation
A) Correct - Checking the newborn's skin for ecchymosis can help identify potential birth-related injuries, as large-for-gestational-age newborns might experience more trauma during delivery.
B) Correct - Breastfeeding can help regulate the newborn's blood glucose levels and provide necessary nutrients.
C) Incorrect- Meconium is the early stool passed by a newborn and might be checked for various reasons but is not specifically related to a large-for-gestational-age newborn.
D) Incorrect- Administering a blood transfusion to a newborn is not typically a part of the care plan for large-for-gestational-age newborns.
E) Correct- The nurse should check the newborn's blood glucose level regularly and provide interventions as needed.
Correct Answer is A
Explanation
A) Correct- Amoxicillin is a safe and effective antibiotic for treating chlamydia infection in pregnant women.
B) Incorrect - Tetracycline and related antibiotics are often used to treat chlamydia, but they are contraindicated during pregnancy due to potential effects on fetal tooth and bone development. is contraindicated in pregnancy because it can cause fetal tooth discoloration and bone deformities.
C) Incorrect- Metronidazole is used for treating bacterial vaginosis and certain other infections, but it is not the first-line treatment for chlamydia.
D) Incorrect- Acyclovir is used to treat herpes simplex virus infections, not chlamydia.
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