Which finding should the practical nurse (PN) instruct the postpartum client to report to the charge nurse?
Increased diaphoresis during the day and night.
Breast engorgement on the fourth postpartum day.
Lochia color that changes to light pink or white.
Sudden or persistent temperature above 100.5 F (38.0 C).
The Correct Answer is D
This is the finding that the PN should instruct the postpartum client to report to the charge nurse because it may indicate an infection, such as endometritis, mastitis, or urinary tract infection, that requires prompt treatment. The PN should also instruct the client to monitor for other signs of infection, such as foul-smelling lochia, redness or tenderness of the breasts, or dysuria.
A. Increased diaphoresis during the day and night is a normal finding in the postpartum period and does not need to be reported. It is caused by hormonal changes and fluid shifts that occur after delivery.
B. Breast engorgement on the fourth postpartum day is a normal finding in the postpartum period and does not need to be reported. It is caused by increased blood flow and milk production in the breasts.
C. Lochia color that changes to light pink or white is a normal finding in the postpartum period and does not need to be reported. It indicates that the uterine lining is healing and regenerating after delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Tell the client that the PN will verify that the dispensed medication is the valid prescription. Choice A rationale:
Explaining that the healthcare provider probably prescribed a different medication while the client is hospitalized (Choice A) may create confusion or concern for the client. It is essential to reassure the client and take appropriate action to address the discrepancy in the appearance of the medication.
Choice C rationale:
Explaining that the pharmacy often substitutes generic equivalents for more expensive brands (Choice C) is not applicable in this situation since the client is expressing concern about the appearance of the medication prescribed by the healthcare provider, not a substitution by the pharmacy.
Choice D rationale:
Telling the client that he is probably confused since being hospitalized tends to disorient clients (Choice D) is dismissive of the client's concerns. It is crucial to acknowledge the client's observation and address the issue professionally.
Correct Answer is A
Explanation
This is the most important follow-up assessment for the PN to implement because it can detect signs of bleeding, infection, or shock that may result from the unsecured surgical dressing. The PN should monitor the client's blood pressure, pulse, temperature, and respiratory rate and report any abnormal changes.
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