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 B
Explanation
The correct answer is choice B: Thick, muffled voice.
Choice B rationale: A thick, muffled voice is a characteristic symptom of epiglottitis. The inflammation and swelling of the epiglottis cause an obstruction in the airway, leading to changes in the child's voice quality.
Choice A rationale: High-pitched wheezing is typically associated with conditions affecting the lower airways, such as asthma or bronchiolitis. Epiglottitis primarily affects the upper airway, causing stridor (a high-pitched, harsh sound during inhalation) rather than wheezing.
Choice C rationale: Purulent nasal discharge is not a typical symptom of epiglottitis. Epiglottitis usually presents with minimal or no secretions, while purulent discharge is more commonly seen in bacterial infections like sinusitis or pneumonia.
Choice D rationale: A productive cough is not a common symptom of epiglottitis. Coughing is associated with conditions affecting the lower respiratory tract, such as bronchitis or pneumonia. Epiglottitis primarily affects the upper airway, causing difficulty breathing and a characteristic "thick, muffled voice."
Correct Answer is B
Explanation
Choice A rationale
Preparing a vacuum is not the first action to take in this situation. A vacuum-assisted delivery might be considered in some cases, but it’s not the immediate action when the fetal head retracts against the perineum.
Choice B rationale
Applying suprapubic pressure is the correct action. This situation describes shoulder dystocia, where the baby’s shoulder gets stuck behind the mother’s pelvic bone during delivery. Suprapubic pressure can help dislodge the baby’s shoulder and allow the delivery to proceed.
Choice C rationale
Applying fundal pressure is not recommended in this situation. Fundal pressure could potentially worsen shoulder dystocia and is generally avoided.
Choice D rationale
Preparing forceps is not the immediate action to take. Forceps may be used in some delivery situations, but in the case of shoulder dystocia, other maneuvers are tried first.
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