The nurse reviews the nurse’s notes and flow chart to identify trends.
Click to specify the notations that require immediate follow up (more than one notation may be correct.)
Exhibit 1: Patient’s Medical History
- Height: 5 ft 6 in (168 cm)
- Weight: 140 lb (63.5 kg)
- Delivery: The patient was transferred to the postpartum unit 1 hour after delivery of a 9 lb 1 oz (4.1 kg) female.
Exhibit 2: Nurse’s Notes and Flow Sheet
The patient was assisted to the bathroom where she voided 150 mL of clear yellow urine. Lochia rubra was moderate with small clots, no foul odor noted. The fundus was firm at the umbilicus. The episiotomy edges were well approximated, with no redness, edema, drainage, or ecchymosis. There was no pain, redness, or swelling in the calves.
- Boggy fundus 1 cm above the umbilicus
- Fundus rotated to the right
- Voided 200 mL of clear yellow urine
Exhibit 3: Vital Signs
- Heart rate: 96 beats/minute
- Blood pressure: 90/62 mm Hg
Exhibit 4: Provider’s Prescriptions
- IV infusing at 125 mL/hr
- A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing.
Exhibit 5: Physical Examination Results
- Episiotomy: Intact with no redness
- Body System: Genital/Urinary and Circulatory
Boggy fundus 1 cm above the umbilicus
Fundus rotated to the right
Blood pressure: 90/62 mm Hg
Voided 200 mL of clear yellow urine
Heart rate: 96 beats/minute
IV infusing at 125 mL/hr
A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing
Episiotomy: Intact with no redness
The Correct Answer is ["A","B","C"]
Based on the provided information, the following notations require immediate follow-up:
- Boggy fundus 1 cm above the umbilicus: A boggy (soft) fundus can indicate uterine atony, a condition in which the uterus fails to contract after delivery. This can lead to postpartum hemorrhage, a serious and potentially life-threatening condition.
- Fundus rotated to the right: A displaced fundus can be a sign of a distended bladder, which can interfere with uterine contraction and lead to postpartum hemorrhage.
- Blood pressure: 90/62 mm Hg: While this blood pressure isn’t extremely low, it is on the lower end of normal. Given the potential for postpartum hemorrhage indicated by the other findings, this should be monitored closely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"}}
Explanation
Based on the provided information, here are the interventions the nurse should perform:
- Check capillary refill on bilateral upper extremities.- Indicated: This is important to assess the client’s circulation, especially given the coolness of the left arm and the fracture in the left shoulder.
- Administer ondansetron 4 mg IV.- Contraindicated: There is no prescription for ondansetron and no indication of nausea or vomiting from the client.
- Inspect the bandage for drainage.- Indicated: Given the client’s recent surgery and the presence of swelling and bruising, it’s important to monitor for any signs of infection or complications.
Correct Answer is B
Explanation
Choice A rationale
While social workers can provide support therapy, they are not typically involved in teaching medical procedures like insulin injection15.
Choice B rationale
Leaving the room and returning later can give the client time to process the information and prepare for learning. It’s important to respect the client’s feelings and readiness to learn15.
Choice C rationale
While it’s true that insulin is a life-saving drug for people with type 1 diabetes, simply explaining this may not address the client’s fears or concerns about self-injection15.
Choice D rationale
Encouraging relaxation techniques can be helpful, but it doesn’t directly address the issue of teaching insulin injection15.
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