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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

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","C"]

Explanation

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.

A. Initiation of peripheral IV access B. X-ray of left shoulder and right knee, STAT C. Computed tomography (CT) of brain, STAT D. Administration of pain medication .

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Initiation of peripheral IV access is a common procedure in the emergency department for patients who have experienced a fall. This allows for the administration of fluids and medications as needed.

Choice B rationale

An X-ray of the left shoulder and right knee would likely be ordered given the patient’s report of pain in his left shoulder after the fall. This would help to identify any fractures or other injuries.

Choice C rationale

A CT scan of the brain may not be necessary in this case, unless the patient was experiencing symptoms such as confusion, loss of consciousness, or other neurological signs following the fall.

Choice D rationale

Administration of pain medication would likely be initiated based on the patient’s report of pain.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C"]

Explanation

On the first day at 1830, certain medical procedures were initiated for the patient.Which of the following procedures were likely to have been initiated based on the patient’s condition?

Correct Answer is ["A","B","D"]

Explanation

The nurse has reviewed the patient’s chart.The nurse recognizes that this patient is hemorrhaging due to which condition?

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