Exhibits
The nurse reviews the nurse's notes and flow chart to identify trends.
Click to specify the notations that require immediate follow up (more than one notation may be correct.)
Body System
Circulatory
- Heart rate 96 beats/minute
- Blood pressure 90/62 mm Hg
- IV infusing at 125 ml/hr
- Respirations 16 breaths/minute
Respiratory
- Oxygen saturation of 89%
- Several deep breaths
Integumentary
- Episiotomy intact with no redness
- Pad is saturated with blood
- 18 gauge IV to left forearm
Genital/Urinary
- Boggy fundus 1 cm above umbilicus
- Fundus rotated to the right
- Voided 200 mL of clear yellow urine
Blood pressure 90/62 mm Hg
Oxygen saturation of 89%
Fundus rotated to the right
Voided 200 mL of clear yellow urine
Oxygen saturation of 89%
IV infusing at 125 ml/hr
The Correct Answer is ["A","B","C"]
Blood pressure 90/62 mm Hg
A blood pressure of 90/62 mm Hg indicates hypotension, which could be indicative of hypovolemia (low blood volume) due to postpartum hemorrhage. Hypotension needs immediate evaluation and intervention to prevent further complications.
Oxygen saturation of 89%
An oxygen saturation of 89% on room air is below the normal range (typically 95-100%). This suggests the client is not adequately oxygenating, which could be due to various reasons such as respiratory compromise or inadequate ventilation. Immediate follow-up is necessary to determine the cause and initiate appropriate interventions.
Fundus rotated to the right
The displacement of the fundus could be due to the presence of a distended bladder pushing the uterus to one side which may increase uterine atony.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale
A. Wearing a face mask is a standard precaution to protect against airborne or droplet transmission of pathogens. However, MRSA is primarily transmitted through direct contact with infected wounds or contaminated surfaces rather than through the air.
B. Contact precautions are essential for preventing the spread of MRSA. These precautions include wearing gloves and gowns when in direct contact with the client or potentially contaminated surfaces. However, this is not of immediate concern.
C. Monitoring the white blood cell count (WBC) is crucial in assessing for signs of infection, including wound infections. An increase in WBC count can indicate systemic infection or local wound infection, which might be related to MRSA. Early detection and prompt reporting allow for timely intervention, such as initiating appropriate antibiotic therapy or further wound assessment.
D. This is because maintaining a clean environment around the wound is crucial to prevent infection
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}
Explanation
After listening to the client's symptoms, the nurse realizes that she likely has acute stress disorderrelated to traumatic stress
Acute Stress Disorder: This diagnosis fits because the client is experiencing significant distress and anxiety related to the traumatic event (her house collapsing during a hurricane). Acute stress disorder is characterized by intrusive thoughts, nightmares, flashbacks, and avoidance behaviors following exposure to a traumatic event. The client's symptoms of persistent thoughts about the event, difficulty sleeping due to these thoughts, and feeling unable to return to her previous emotional state ("funk") are indicative of acute stress disorder.
Traumatic Stress: This describes the source of the client's symptoms. The collapse of her house during a hurricane is a traumatic event that has triggered her acute stress disorder symptoms. Traumatic stress refers to the psychological and emotional response to a deeply distressing or disturbing event.
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