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 B
Explanation
Your baby can lose 5% of body weight during the first 3 days of life. This is a normal physiological process that happens as your baby adjusts to breastfeeding and expels excess fluids. Your baby should regain this weight by 10 to 14 days of age.
Choice A is incorrect because your baby does not need to feed constantly in the first week of life. Your baby should feed at least eight times in 24 hours but may have periods of cluster feeding where they feed more frequently for a few hours.
Choice C is incorrect because your baby should have more than 5 wet diapers per day after the fourth day of life. This is a sign that your baby is getting enough milk and is well-hydrated.
Choice D is incorrect because your baby should gain more than 0.25 oz (7 grams) per day after the fourth day of life. The average weight gain for a breastfed baby is about 0.5 to 1 oz (14 to 28 grams) per day in the first month.
Correct Answer is D
Explanation
Ineffective airway clearance related to mucus and water secretions. This is because newborns who are born via cesarean delivery are at risk for respiratory distress due to the lack of compression of the chest during birth. This can result in retained mucus and fluid in the lungs that can interfere with breathing and oxygenation. The nurse should prioritize clearing the airway and monitoring the respiratory status of the newborn.
Choice A is wrong because ineffective thermoregulation related to heat loss to the environment is not specific to cesarean delivery. All newborns are prone to heat loss due to their large surface area and thin skin. The nurse should maintain a warm and dry environment for the newborn and prevent exposure to cold surfaces.
Choice B is wrong because altered nutrition less than the body requirement related to limited formula intake is not specific to cesarean delivery. All newborns need adequate nutrition to support their growth and development. The nurse should monitor the intake and output of the newborn and assist with feeding as needed.
Choice C is wrong because altered urinary elimination related to post- circumcision status is not specific to cesarean delivery. Circumcision is an elective procedure that may or may not be performed on male newborns. The nurse should provide wound care and pain relief for the circumcised newborn and observe for signs of infection or bleeding.
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