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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
Asking why the adolescent is requesting birth control may come across as judgmental and could discourage open communication.
Choice B rationale
Understanding what the adolescent knows about contraception can help guide the discussion and ensure that she is making an informed decision.
Choice C rationale

Whether or not the partner loves the adolescent is not directly relevant to the decision to use birth control. The focus should be on the adolescent’s reproductive health and autonomy.
Choice D rationale
While it’s important to discuss coercion in sexual relationships, this question could be seen as intrusive or presumptive. It’s more appropriate to provide information about healthy relationships and consent.

A. The uterine fundus is 2 cm above the umbilicus B. The client urinates 30 ml/h C. The client does not feel the urge to urinate D. The bladder is distended upon palpation .

Correct Answer is B

Explanation

Choice A rationale
The position of the uterine fundus is not directly related to the client’s ability to void effectively.
Choice B rationale
A client urinating 30 ml/h indicates that the client is able to void effectively. This is the minimum acceptable urine output in an adult client.
Choice C rationale

Not feeling the urge to urinate could indicate a problem such as urinary retention.
Choice D rationale
A distended bladder upon palpation could indicate urinary retention, which means the client is not voiding effectively.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a clinic is caring for an adolescent patient who requests a prescription for birth control. Which of the following Questions should the nurse ask?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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

Exhibits