A patient was received one hour after delivering a 9 lb 1 oz (4.1 kg) female baby
Which of the following assessment findings requires immediate follow-up by the nurse?
Her vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale.
She was assisted to the bathroom where she voided 150 mL of clear yellow urine.
Lochia rubra is moderate with small clots, no foul odor noted
The fundus is firm at the umbilicus.
The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis.
There is no pain, redness, or swelling in the calves.
A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag.
The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.
Correct Answer : A,B,C,D,E,F,G,H
Step 1: The patient’s vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale.
Step 2: She was assisted to the bathroom where she voided 150 mL of clear yellow urine. Lochia rubra is moderate with small clots, no foul odor noted. The fundus is firm at the umbilicus. The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis. There is no pain, redness, or swelling in the calves.
Step 3: A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag. The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Flaring of the nares is a sign of respiratory distress in children. It indicates that the child is working harder to breathe.
Choice B rationale
Bilateral bronchial breath sounds are normal and do not indicate acute respiratory distress.
Choice C rationale
Diaphragmatic respirations are normal in children and do not indicate acute respiratory distress.
Choice D rationale
A resting respiratory rate of 35 breaths/minute is within the normal range for a preschoolaged child and does not indicate acute respiratory distress.
Correct Answer is ["A","B"]
Explanation
The correct answer is choiceA. Manual resuscitation bagandB. An advanced airway kit.
Choice A rationale:
A manual resuscitation bag is essential in pediatric emergencies to provide immediate ventilation support if the child experiences respiratory failure. Given the child’s symptoms of fast and noisy breathing, there is a risk of respiratory distress, making this equipment crucial.
Choice B rationale:
An advanced airway kit is necessary to secure the airway in case of severe respiratory distress or failure. This kit includes tools for intubation, which may be required if the child’s condition deteriorates and manual ventilation is insufficient.
Choice C rationale:
A dose of subcutaneous epinephrine is typically used for anaphylactic reactions. While it is a critical medication in emergencies involving severe allergic reactions, it is not directly related to managing respiratory distress caused by infections or other non-allergic conditions.
Choice D rationale:
The child’s favorite toy can provide comfort and reduce anxiety during medical procedures. However, it is not a critical item for the immediate management of respiratory distress or for the placement of an intravenous line.
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