“A nurse is assessing a patient who is 3 days postpartum.

Which of the following findings should the nurse report to the provider?”

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.

Choice A rationale
Turning a baby’s car seat forward when they are 1 year old is not recommended. According to the American Academy of Pediatrics, children should ride in a rear-facing car seat as long as possible, until they reach the highest weight or height allowed by their seat. This is because rear-facing car seats provide the best protection for the baby’s head, neck, and spine in a crash.
Choice B rationale
While it’s important to keep a baby warm in the car seat, using a sleep sack is not the safest option. Bulky outerwear and blankets can interfere with the tightness of the harness, which can compromise the safety of the baby. Instead, it’s recommended to dress the baby in lighter layers and place a warm blanket over them and the harness.
Choice C rationale
A car seat challenge test, also known as a car seat trial, is usually performed on babies who were born preterm, not at full term. This test checks whether the baby can sit in a car seat safely without any breathing problems or other complications. Since the newborn in question was delivered at 38 weeks of gestation, which is considered full term, a car seat challenge test is not typically required.
Choice D rationale
The car seat should indeed be positioned at a 45-degree angle. This angle is especially important for newborns and infants who are rear-facing, as it helps to support their head and prevent it from falling forward.