“A nurse is assessing a patient who is 3 days postpartum.
Which of the following findings should the nurse report to the provider?”
“Heart rate 89/min.”.
“Cool, clammy skin.”.
“BP 120/70 mm Hg.”.
“Moderate lochia serosa.”.
The Correct Answer is B
Choice A rationale
A heart rate of 89/min is within the normal range for an adult, and would not typically be a cause for concern.
Choice B rationale
Cool, clammy skin can be a sign of shock or other serious conditions such as hypoperfusion or inadequate blood flow, which could be a sign of hemorrhage or other circulatory issues. This is a significant finding that should be reported to the provider immediately. Hypoperfusion can lead to inadequate oxygen supply to the body’s organs and tissues, which can result in organ failure and other serious complications. Therefore, any signs of hypoperfusion, including cool, clammy skin, should be reported to the provider immediately for further evaluation and treatment.
Choice C rationale
A blood pressure of 120/70 mm Hg is within the normal range for an adult, and would not typically be a cause for concern.
Choice D rationale
Moderate lochia serosa is a normal finding in a woman who is 3 days postpartum. Lochia serosa is the term for the pink or brownish discharge that occurs after lochia rubra, the bright red discharge that occurs immediately after childbirth. Lochia serosa typically begins about 3- 4 days after delivery and can continue for up to 10 days postpartum.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While initiating an infusion of IV fluids for the patient is important, it is not the immediate next step after noticing a protruding umbilical cord.
Choice B rationale
Administering oxygen via a nonrebreather mask at 8L/min is a later step in the management of umbilical cord prolapse.
Choice C rationale
The immediate next step after noticing a protruding umbilical cord is to perform a vaginal examination and apply upward pressure on the presenting part to relieve cord compression.
Choice D rationale
Covering the umbilical cord with a sterile saline-saturated towel is a later step in the management of umbilical cord prolapse.
Correct Answer is C
Explanation
Choice A rationale
Pale, translucent skin is not typically a characteristic of a postterm newborn. Postterm newborns often have dry, peeling, loose skin.
Choice B rationale
Large deposits of subcutaneous fat are not usually seen in postterm newborns. In fact, these babies may appear abnormally thin, especially if the function of the placenta was severely reduced near the end of the pregnancy.
Choice C rationale
Nails extending over the tips of the fingers is indeed a common characteristic of postterm newborns. This is because the baby has had more time to grow in the womb.
Choice D rationale
A thin covering of fine hair on the shoulders and back is not typically seen in postterm newborns. This characteristic is more commonly associated with preterm babies.
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