The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. Based on these symptoms, the nurse should:
Document expected postpartum mucous membrane congestion
Notify the charge nurse of a possible upper respiratory infection
Notify the physician of a possible pulmonary embolism
Medicate with antipyretic remedy for elevated temperature
The Correct Answer is C
Notify the physician of a possible pulmonary embolism. This is because the client's symptoms suggest that she has a pulmonary embolism, which is a blockage of a blood vessel in the lungs often caused by blood clots that travel from the legs. Pulmonary embolism is a life-threatening condition that requires immediate medical attention. The client may also have chest pain, coughing up blood, dizziness, or fainting.
Choice A is wrong because postpartum mucous membrane congestion does not cause fever, cough, or shortness of breath.
Choice B is wrong because an upper respiratory infection does not cause edema and redness along the saphenous vein.
Choice D is wrong because an antipyretic remedy does not treat the underlying cause of the fever and may mask the severity of the condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The Moro reflex was elicited. This is because the Moro reflex is a normal newborn reflex that occurs when the baby is startled by a loud noise or a sudden movement. The baby responds by extending the arms and legs, opening the hands, and then bringing the arms and legs back to the chest.
The Moro reflex is present at birth and disappears by 3 to 6 months of age.
Choice B is wrong because this is not abnormal for a full-term infant. The Moro reflex is a sign of a healthy nervous system and brain development.
Choice C is wrong because there is no evidence of an abnormality in the musculoskeletal system. The Moro reflex does not indicate any problems with the bones or muscles of the baby.
Choice D is wrong because the full-term infant should react to sudden movement. The Moro reflex is a protective response that helps the baby cling to the mother in case of danger.
Correct Answer is B
Explanation
Pathologic jaundice. This type of jaundice occurs within the first 24 hours of birth and is caused by an underlying health condition, such as blood type incompatibility, infection, or liver problems. It can lead to serious complications, such as brain damage, if not treated promptly. Pathologic jaundice requires medical attention and often involves phototherapy or blood transfusion to lower the bilirubin levels in the baby's blood.
Choice A is not correct because physiologic jaundice is a normal and harmless condition that affects most newborns. It usually appears between the second and fourth day after birth and resolves by the second week. It is caused by the immature liver's inability to process bilirubin efficiently.
Choice C is not correct because breast milk jaundice is a rare condition that affects some breastfed babies. It usually appears after the first week of life and lasts up to a month or longer. It is caused by a substance in breast milk that interferes with the liver's ability to eliminate bilirubin.
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