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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: Enhance uterine contractions. This is an incorrect answer that contradicts the effect of narcotic analgesia on uterine activity. Narcotic analgesia can reduce uterine contractions by decreasing maternal catecholamine levels, which can prolong labor or increase bleeding.
Choice B Reason: Be used in place of preoperative sedation. This is an irrelevant answer that does not apply to this scenario. Preoperative sedation is a medication given before surgery to reduce anxiety, pain, or nausea. Narcotic analgesia can be used as a preoperative sedative, but it is not related to labor or delivery.
Choice C Reason: Result in neonatal respiratory depression. This is because narcotic analgesia can cross the placenta and affect the fetal central nervous system, which can cause decreased respiratory drive, apnea, bradycardia, or hypotonia in the newborn. The risk of neonatal respiratory depression is higher when narcotic analgesia is administered close to delivery, as there is less time for placental clearance or maternal metabolism.
Choice D Reason: Prevent the need for anesthesia with an episiotomy. This is an inaccurate answer that overestimates the effect of narcotic analgesia on perineal pain. Narcotic analgesia can provide some relief of labor pain, but it does not block pain sensation completely or locally. An episiotomy is a surgical incision made in the perineum to enlarge the vaginal opening during delivery, which requires local anesthesia or regional anesthesia (such as epidural or spinal). Narcotic analgesia does not prevent or replace anesthesia with an episiotomy.
Correct Answer is D
Explanation
Choice A Reason: Apical pulse of 148 beats per minute. This is not a finding that would support a diagnosis of RDS, but rather a normal finding for a newborn. A normal apical pulse for a newborn ranges from 120 to 160 beats per minute. A high pulse rate may indicate fever, infection, anemia, or dehydration. A low pulse rate may indicate hypothermia, hypoxia, or heart block.
Choice B Reason: Respiratory rate of 40 during sleep. This is not a finding that would support a diagnosis of RDS, but rather a normal finding for a newborn. A normal respiratory rate for a newborn ranges from 40 to 60 breaths per minute. A high respiratory rate may indicate respiratory distress, infection, or metabolic acidosis. A low respiratory rate may indicate respiratory depression, hypothermia, or narcotic exposure.
Choice C Reason: Skin color jaundiced. This is not a finding that would support a diagnosis of RDS, but rather a different condition called jaundice. Jaundice is a yellowish discoloration of the skin and mucous membranes caused by elevated levels of bilirubin in the blood. Bilirubin is a breakdown product of hemoglobin that is normally excreted by the liver and kidneys. Jaundice can occur in newborns due to immature liver function, increased red blood cell breakdown, or blood group incompatibility. Jaundice does not affect lung function or oxygenation.
Choice D Reason: Chest retractions. This is because chest retractions are a sign of respiratory distress that indicate increased work of breathing and reduced lung compliance. Chest retractions occur when the chest wall sinks in between the ribs or below the sternum during inhalation, creating a negative pressure that helps draw air into the lungs. RDS is a serious condition where the newborn's lungs are immature and lack sufficient surfactant, which is a substance that reduces surface tension and prevents alveolar collapse. RDS can cause respiratory distress, hypoxia, acidosis, and organ failure. It is more common in preterm infants, especially those born before 37 weeks' gestation.
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