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 B
Explanation
A) Incorrect- Scheduling a routine 1-month appointment is not appropriate given the elevated glucose value. A 1-hour glucose screening test value of 130 mg/dL indicates an elevated glucose level, which suggests the need for further testing to confirm or rule out gestational diabetes.
B) Correct - An elevated glucose value on the initial screening test requires confirmation through a more comprehensive test, such as the 3-hour oral glucose tolerance test.
C) Incorrect- Home glucose monitoring might be indicated for gestational diabetes but is not the next step after an elevated 1-hour glucose screening test.
D) Incorrect- Repeating the 1-hour glucose test in 1 week is not necessary; if the initial test is elevated, further testing is required.
Correct Answer is C
Explanation
A) Incorrect- Keeping the cord covered with a diaper is not recommended, as it can trap moisture and delay cord drying.
B) Incorrect- Cleaning the cord with antibacterial soap is not necessary and can actually interfere with the natural drying process.
C) Correct - Notifying the provider about odor coming from the cord is important, as it could indicate infection.
D) Incorrect- Some oozing of blood is normal as the cord stump dries, but bright red bleeding might be a sign of a problem and should be evaluated by a healthcare provider.
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