The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?
Report heart rate to healthcare provider.
Assess perineum for excessive lochia.
Document the vital signs in the record.
Administer a PRN dose of acetaminophen.
The Correct Answer is C
Choice A rationale
A heart rate of 58 beats/minute is within the normal range for adults, including those who have recently given birth. Therefore, there is no need to report this to the healthcare provider.
Choice B rationale
While assessing for excessive lochia is important in postpartum care, there is no indication from the given vital signs that this is necessary.
Choice C rationale
The vital signs provided are all within normal ranges for a postpartum patient. Therefore, the appropriate action would be to document these findings in the patient’s record.
Choice D rationale
There is no indication from the given vital signs that the patient has a fever or pain, so administering a PRN dose of acetaminophen is not necessary.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Disseminated intravascular coagulation (DIC) is a serious complication that can occur after severe postpartum hemorrhage. It involves an abnormal activation of the clotting cascade, leading to the formation of small blood clots in the vessels and can result in organ damage.
Choice B rationale
Postpartum psychosis is a rare psychiatric emergency that typically presents with delirium and mood disturbances, and it is not directly related to postpartum hemorrhage.
Choice C rationale
While hard, painful uterine afterpains can occur after childbirth, they are not the highest priority for assessment in a client who experienced a severe postpartum hemorrhage.
Choice D rationale
Placenta accreta is a condition where the placenta attaches too deeply into the uterine wall. However, it is typically identified during pregnancy or at the time of delivery, not after a postpartum hemorrhage.
Correct Answer is B
Explanation
Choice A rationale
Nonstimulant medications can be beneficial in the treatment of ADHD. They are often used when stimulant medications are not effective or cause bothersome side effects.
Choice B rationale
Designating an established area for study is a beneficial strategy for children with ADHD. It helps to create a structured environment which can aid in focusing and completing tasks.
Choice C rationale
Being diagnosed with ADHD does not automatically qualify a child for a specialized education plan. Each child’s needs are evaluated individually, and while some may benefit from a specialized plan, it is not a universal requirement.
Choice D rationale
While creating an organization chart for tasks can be helpful for some children with ADHD, understanding this strategy does not necessarily demonstrate an understanding of the overall treatment for ADHD45.
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