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 B

Explanation

Fundus firm, at the level of the umbilicus. This is because the normal postpartum uterine fundus location should be around the belly button (umbilicus) one hour after delivery and then decrease by 1 cm per 24 hours. A firm fundus indicates that the uterus is contracting well and preventing bleeding.

Choice A is wrong because a soft fundus indicates uterine atony, which is a risk factor for hemorrhage.

Choice C is wrong because the fundus should not be above the umbilicus 12 hours after delivery.

Choice D is wrong because a fundus to the right of the umbilicus indicates a full bladder, which can displace the uterus and cause bleeding.

A. Administer oxytocin. B. Observe for pooling of blood under the buttocks. C. Check the client's blood pressure. D. Massage the client's fundus.

Correct Answer is D

Explanation

Massage the client’s fundus. This is because the most common cause of postpartum hemorrhage is uterine atony, which is the failure of the uterus to contract after delivery. Massaging the fundus can stimulate uterine contractions and reduce bleeding by compressing the blood vessels at the placental site.

Choice A is not correct because administering oxytocin is not the first action to take. Oxytocin is a medication that can also help the uterus contract, but it should be given after assessing the uterine tone and bleeding.

Choice B is not correct because observing for pooling of blood under the buttocks is not a priority action. It can help estimate the amount of blood loss, but it does not address the cause of bleeding or stop it.

Choice C is not correct because checking the client’s blood pressure is not the first action to take. Blood pressure can indicate hypovolemia due to blood loss, but it is not a sensitive indicator and may remain normal until a significant amount of blood is lost.

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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 nurse is collecting data from a client who is 12 hr postpartum. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is caring for a postpartum client who saturates a perineal pad in 10 minutes. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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