When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation?
Select one:
Moderate amounts of deep red lochia.
Sweating while afebrile.
Voiding 350 mL of blood-tinged urine.
Heart rate of 115 beats/minute.
The Correct Answer is D
Choice A Reason: Moderate amounts of deep red lochia. This is not a finding that would warrant further investigation, but rather a normal finding for the early postpartum period. Lochia is the vaginal discharge that occurs after delivery, which consists of blood, mucus, and tissue from the uterus. Lochia is usually deep red in color and moderate in amount for the first few days after delivery.
Choice B Reason: Sweating while afebrile. This is not a finding that would warrant further investigation, but rather a common occurrence in the postpartum period. Sweating is a mechanism of thermoregulation that helps the body eliminate excess fluid and electrolytes that were retained during pregnancy. Sweating does not necessarily indicate fever or infection.
Choice C Reason: Voiding 350 mL of blood-tinged urine. This is not a finding that would warrant further investigation, but rather an expected outcome for the postpartum period. Voiding large amounts of urine is normal in the postpartum period, as the body eliminates the excess fluid that was accumulated during pregnancy. Blood-tinged urine may be due to trauma or irritation of the urinary tract during labor or delivery, which usually resolves within a few days.
Choice D Reason: Heart rate of 115 beats/minute. This is because a heart rate of 115 beats/minute is higher than the normal range for an adult, which is 60 to 100 beats/minute. A high heart rate may indicate postpartum hemorrhage, infection, pain, anxiety, or dehydration. The nurse should further assess the client for other signs and symptoms of these conditions and notify the physician if necessary.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: Two arteries, one vein. This is because two arteries and one vein are the normal components of the umbilical cord, which is a structure that connects the fetus to the placenta and provides blood circulation between them. The umbilical cord carries oxygenated blood from the placenta to the fetus through the umbilical vein, and deoxygenated blood from the fetus to the placenta through the umbilical arteries.
Choice B Reason: Two veins, one artery. This is an incorrect answer that indicates an abnormal anatomy of the umbilical cord, which is known as single umbilical artery (SUA). SUA is a condition where there is only one umbilical artery instead of two, which can reduce blood flow and oxygen delivery to the fetus. SUA can be associated with congenital anomalies or growth restriction in some cases.
Choice C Reason: Two veins, two arteries. This is an incorrect answer that indicates an abnormal anatomy of the umbilical cord, which is known as double umbilical vein (DUV). DUV is a condition where there are two umbilical veins instead of one, which can increase blood flow and oxygen delivery to the fetus. DUV can be associated with fetal overgrowth or polycythemia in some cases.
Choice D Reason: One artery, one vein. This is an incorrect answer that indicates an abnormal anatomy of the umbilical cord, which is also known as single umbilical artery (SUA). SUA is a condition where there is only one umbilical artery instead of two, which can reduce blood flow and oxygen delivery to the fetus. SUA can be associated with congenital anomalies or growth restriction in some cases.
Correct Answer is D
Explanation
Choice A Reason: Daily weight. This is an incorrect answer that indicates a valid parameter to assess hydration status. Daily weight is a measure of the body mass that can reflect changes in fluid balance. Daily weight can help detect fluid loss or gain in premature infants, who are more prone to dehydration or overhydration due to immature renal function and high insensible water loss.
Choice B Reason: Consistency of stool. This is an incorrect answer that indicates a valid parameter to assess hydration status. Consistency of stool is a measure of the texture and form of feces that can reflect changes in fluid intake and absorption. Consistency of stool can help identify diarrhea or constipation in premature infants, who are more susceptible to gastrointestinal problems such as necrotizing enterocolitis or feeding intolerance.
Choice C Reason: Volume of urine output. This is an incorrect answer that indicates a valid parameter to assess hydration status. Volume of urine output is a measure of the amount of urine produced and excreted by the kidneys that can reflect changes in fluid balance and renal function. Volume of urine output can help monitor hydration status and kidney function in premature infants, who are more vulnerable to fluid overload or deficit and renal impairment.
Choice D Reason: Blood pH. This is because blood pH is a measure of the acidity or alkalinity of the blood, which reflects the balance between carbon dioxide and bicarbonate in the body. Blood pH is not a direct indicator of hydration status, which refers to the amount of water and electrolytes in the body. Hydration status can affect blood pH, but blood pH can also be influenced by other factors such as respiratory or metabolic disorders.
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