“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 A
Explanation
Choice A rationale
The instillation of antibiotic ophthalmic ointment is delayed to facilitate bonding between the newborn and the parent. Immediate skin-to-skin contact between the newborn and the parent has been shown to have several benefits, including stabilizing the newborn’s heart rate, temperature, and breathing, stimulating digestion, helping the newborn to sleep, promoting weight gain, and aiding in maternal attachment.
Choice B rationale
The newborn’s weight does not affect the timing of the instillation of antibiotic ophthalmic ointment.
Choice C rationale
Manifestations of infection in the newborn’s eyes would not be immediately apparent following birth, so this would not be a reason to delay the instillation of antibiotic ophthalmic ointment.
Choice D rationale
The mode of delivery, whether vaginal or cesarean, does not affect the timing of the instillation of antibiotic ophthalmic ointment.
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