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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Related Questions
Correct Answer is D
Explanation
Choice A rationale
While acknowledging the child’s knowledge about the upcoming operation is important, it does not provide the child with an opportunity to express their understanding or feelings about the operation.
Choice B rationale
Reassuring the child about the care they will receive is important, but it does not encourage the child to express their understanding or feelings about the operation.
Choice C rationale
Asking the child if they are scared might lead the child to focus on their fear, rather than helping them understand the operation.
Choice D rationale
Asking the child to explain what an operation is can help the healthcare provider assess the child’s understanding of the operation. It also provides an opportunity to correct any misconceptions and provide appropriate information.
Correct Answer is B
Explanation
Choice A rationale
While contact precautions can be important in managing some infections, they are not the primary reason for hospitalization in the case of PID891011.
Choice B rationale
Hospitalization for PID is often recommended for the administration of a supervised parenteral antibiotic protocol. This allows for the direct administration of antibiotics into the bloodstream, which can be more effective in severe cases.
Choice C rationale
The Jarisch-Herxheimer reaction is a reaction to endotoxin-like products released by the death of harmful microorganisms within the body during antibiotic treatment. It is not a primary reason for hospitalization in the treatment of PID891011.
Choice D rationale
While the collection of serial anaerobic cultures of vaginal discharge can be part of the diagnostic process for PID, it is not the primary reason for hospitalization.
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