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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 A

Explanation

Choice A rationale
Puncturing the lateral side of the heel is the correct procedure when performing a heel stick on a newborn. This area is less likely to come into contact with hard surfaces that could cause injury to the puncture site.
Choice B rationale
A 21-gauge needle is too large for a heel stick procedure on a newborn. A smaller gauge needle or a lancet is typically used to ensure the puncture is as small and painless as possible.
Choice C rationale
Applying an alcohol pad to the site after the procedure is not recommended. Alcohol can cause skin irritation and dryness. Instead, a sterile gauze or bandage is usually applied to stop any bleeding from the puncture site.
Choice D rationale
Placing a cold cloth at the site for 15 minutes before the procedure is not recommended. Cold can cause vasoconstriction, which would make it more difficult to obtain a blood sample.
Instead, warming the heel prior to the stick can help to increase blood flow to the area.

A. The client’s fundus is firm and midline. B. The client saturates a perineal pad in 1 hr. C. The client reports a feeling of vaginal fullness. D. The client’s umbilical cord lengthens.

Correct Answer is A

Explanation

Choice A rationale
The therapeutic effect of IV oxytocin administration following expulsion of the placenta is a firm and midline fundus. Oxytocin stimulates uterine contractions, which helps the uterus return to its pre-pregnancy size and position.
Choice B rationale
Saturating a perineal pad in 1 hr is not a therapeutic effect of oxytocin. This could be a sign of postpartum hemorrhage.
Choice C rationale
A feeling of vaginal fullness is not a therapeutic effect of oxytocin. This could be a sign of a vaginal hematoma.
Choice D rationale
The client’s umbilical cord lengthening is not a therapeutic effect of oxytocin. This could be a sign of placental separation.

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

Nursing Test Bank

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Exhibits