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

Choice A rationale

High-density lipoprotein (HDL) cholesterol is known as the “good” cholesterol because it helps remove other forms of cholesterol from your bloodstream. Higher levels of HDL cholesterol are associated with a lower risk of heart disease. Therefore, an HDL level of 85 mg/dL (2.2 mmol/L) is helpful in reducing cardiac risk.

Choice B rationale

Encouraging the client to reduce consumption of fatty foods is not necessary in this case as the client’s HDL level is already high, which is beneficial for heart health.

Choice C rationale

Asking the client about hereditary cardiac risk factors is not the most relevant action in this case. The client’s HDL level is already high, which is beneficial for heart health.

Choice D rationale

Explaining that the client may need medication therapy is not necessary in this case as the client’s HDL level is already high, which is beneficial for heart health.

Choice A rationale

The statement “This diagnosis means that I am crazy” requires follow-up teaching by the nurse. Mental health conditions do not equate to being “crazy”. It’s important to educate the client about the nature of their diagnosis and dispel any misconceptions.

Choice B rationale

The statement “Many people have the same response to a stressful situation as I am having right now” does not require follow-up teaching. It shows that the client understands that their reaction to stress is not uncommon.

Choice C rationale

The statement “I will probably need to be on medication for the rest of my life” requires follow-up teaching. While some conditions do require long-term medication, it’s not a certainty for all conditions. The duration of treatment can vary based on the individual’s response and the nature of their condition.

Choice D rationale

The statement “I can use holistic approaches like meditation to help my symptoms” does not require follow-up teaching. It shows that the client is open to using non-pharmacological methods to manage their symptoms, which can be a beneficial part of a comprehensive treatment plan.

Choice E rationale

The statement “I am at high risk for post-traumatic stress disorder because I have acute stress disorder” does not require follow-up teaching. It’s accurate that individuals with acute stress disorder are at a higher risk of developing post-traumatic stress disorder.

Choice F rationale

The statement “I can learn to manage my thoughts better through therapy” does not require follow-up teaching. It shows that the client understands the benefits of therapy in managing their condition.