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Select all that apply. Which of the following findings require immediate follow-up?

Exhibits

Temperature

Pulse rate

Respiratory rate

Blood pressure

Lochia

Pain

Edema

Answer and Explanation

Correct Answer : A,B,D,E,G

Choice A rationale: The client’s temperature is 38.3°C (101°F), which is above the normal range (36.5-37.2°C or 97.7-99°F). This could indicate an infection, which is a common postpartum complication. Fever in the postpartum period can be due to endometritis, wound infection, mastitis, or urinary tract infection. Given the client’s report of a burning sensation during urination, a urinary tract infection could be a possibility. This finding requires immediate follow-up.

Choice B rationale: The client’s pulse rate is 110/min, which is above the normal range (60-100/min). This could indicate tachycardia, which can be a response to fever, pain, anxiety, or blood loss. Given the client’s elevated temperature and report of pain, this finding requires immediate follow-up.

Choice C rationale: The client’s respiratory rate is 22/min, which is within the normal range (12-20/min). While it’s slightly elevated, it’s not as concerning as the other findings. However, the nurse should continue to monitor the client’s respiratory rate along with other vital signs.

Choice D rationale: The client’s blood pressure is 140/90 mm Hg, which is higher than the normal range (90-120/60-80 mm Hg). This could indicate hypertension, which can be a complication in the postpartum period. Hypertension can lead to complications such as preeclampsia or eclampsia, which can be life-threatening. This finding requires immediate follow-up.

Choice E rationale: The client has a large amount of lochia rubra. Lochia rubra is normal for the first few days after delivery, but a large amount could indicate postpartum hemorrhage, especially if it’s accompanied by signs of hypovolemia such as tachycardia and hypotension. This finding requires immediate follow-up.

Choice F rationale: The client reports pain as 5 on a scale of 0 to 10. While pain is expected after a vaginal delivery, especially with an episiotomy, it should be manageable with analgesics. If the client’s pain is not well-controlled, it could indicate a complication such as infection or hematoma at the episiotomy site. However, given the information provided, this finding does not require immediate follow-up as much as the others.

Choice G rationale: The client has 3+ peripheral edema in bilateral lower extremities. While some edema is normal during pregnancy and the postpartum period, 3+ edema could indicate a complication such as deep vein thrombosis, especially if it’s accompanied by pain, warmth, or redness. This finding requires immediate follow-up.

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Correct Answer is B

Explanation

Choice A rationale
Preparing the client to receive a plasma expander is not the first action the nurse should take. While it may be necessary in severe cases of hemorrhage, the first action should be to ensure the client’s oxygenation.
Choice B rationale
Administering oxygen via face mask at 10 L/min is the first action the nurse should take. This is because a client who is saturating perineal pads every 10 to 15 minutes is likely experiencing a significant blood loss, which can lead to hypoxia.
Choice C rationale
Inserting an indwelling urinary catheter may be necessary in some cases, but it is not the first action the nurse should take.
Choice D rationale
Collecting hemoglobin and hematocrit levels is important to assess the extent of blood loss, but it is not the first action the nurse should take.

A. The client is changing the perineal pad once daily. B. The client cleans the perineum with a squeeze bottle after urinating. C. The client’s perineal suture line is well approximated. D. The client is using witch hazel pads on the perineum.

Correct Answer is A

Explanation

Choice A rationale

Changing the perineal pad only once daily can lead to an increased risk of infection, which can delay wound healing. It’s important to maintain cleanliness in the perineal area, especially after a laceration, to promote healing.
Choice B rationale
Cleaning the perineum with a squeeze bottle after urinating is actually a recommended practice. It helps to keep the area clean and reduce the risk of infection.
Choice C rationale
A well-approximated perineal suture line is a positive sign of healing. It indicates that the edges of the wound are close together, which promotes healing and reduces the risk of infection.
Choice D rationale
Using witch hazel pads on the perineum can provide relief from discomfort and has astringent properties that can promote healing.

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Select all that apply. Which of the following findings require immediate follow-up? Exhibits

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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Select all that apply. Which of the following findings require immediate follow-up?

Exhibits