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.
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
This action helps to prevent cold stress. This is because cold stress is a condition where the newborn's core temperature drops below 36.5°C and they use energy and oxygen to generate warmth. This can lead to hypoglycemia, metabolic acidosis, hypoxia, and an increased risk of infection.
Placing the newborn under a radiant warmer provides thermal stability and prevents heat loss by radiation.
Choice B is wrong because thermogenesis is the process of heat production, not a complication.
Choice C is wrong because shivering is a mechanism of heat production in adults, not in newborns.
Choice D is wrong because brown fat production is a normal feature of newborns that helps them generate heat by lipolysis.
Here is an image of a newborn under a radiant warmer.
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