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

Answer and Explanation

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.

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Correct Answer is A

Explanation

This can be from the sudden withdrawal of your hormones. It's not a cause for alarm. This is because newborn female babies may have a little bloody vaginal discharge in their diaper due to the withdrawal of maternal hormones after delivery. This usually stops as the hormones return to normal levels¹².

Choice B is wrong because the baby does not need an appointment for this condition.

Choice C is wrong because the mother does not need to watch her baby for this condition.

Choice D is wrong because the blood is not related to cleaning her perineal area.

A. Using a 21 gauge needle. B. Injecting at a 45-degree angle. C. Injecting 1cc of medication. D. Injecting the medication into the vastus lateralis.

Correct Answer is D

Explanation

Injecting the medication into the vastus lateralis. This is because the vastus lateralis is a large muscle in the thigh that is suitable for intramuscular injections in newborns³. The vitamin K injection helps prevent vitamin K deficiency bleeding, which is a rare but serious condition that can cause bleeding in the brain or other organs¹. The American Academy of Pediatrics recommends that all newborns receive a single intramuscular dose of 0.5 to 1 mg of vitamin K within one hour of birth².

Choice A is wrong because a 21 gauge needle is too large for a newborn's muscle. A 25 or 27 gauge needle is more appropriate.

Choice B is wrong because injecting at a 45-degree angle may not reach the muscle tissue. A 90-degree angle is more appropriate.

Choice C is wrong because injecting 1cc of medication is too much for a newborn's muscle. The recommended dose of vitamin K is 0.5 to 1 mg, which is equivalent to 0.05 to 0.1 mL.

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The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. Based on these symptoms, the nurse should:

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Naxlex Comprehensive Predictor Exams

A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse?

Correct Answer is A

Explanation

The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client?

Correct Answer is D

Explanation

A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse?

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hr ago. The nurse should identify which of the following findings places the client at risk for a postpartum hemorrhage.

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?

The first sign of hypovolemic shock from postpartum hemorrhage is likely to be:

When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?

To prevent possible retinopathy in a preterm infant requiring oxygen therapy, the nurse will:

A nurse is teaching a new mother about signs of effective breastfeeding of her newborn. Which of the following information should the nurse include in the teaching?

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?