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 A
Explanation
The correct answer is choice A: Descriptions of numbness and tingling in fingers distal to the AVF.
Choice A rationale:
Descriptions of numbness and tingling in fingers distal to the arteriovenous fistula (AVF) suggest possible nerve compression or impaired blood flow, which are concerning findings. These symptoms could indicate reduced perfusion to the distal extremities and require immediate attention to prevent further complications.
Choice B rationale:
A loud and consistent bruit auscultated at the AVF site is an expected finding and indicates adequate blood flow through the fistula. A bruit is the sound of turbulent blood flow and is commonly heard over functional AV fistulas.
Choice C rationale:
Bruising at the AVF site is a common occurrence after the creation of the fistula. It is expected due to the surgical intervention and the manipulation of blood vessels. As long as the bruising is not severe or accompanied by other concerning symptoms, it does not need immediate reporting.
Choice D rationale:
The absence of the radial pulse distal to the AVF and the presence of the ulnar pulse are normal findings in a functioning AV fistula. The AV fistula diverts blood flow away from the radial artery, leading to a diminished pulse. This is not a cause for concern as long as the ulnar pulse is present, indicating adequate perfusion to the hand.
Correct Answer is D
Explanation
The PN should directly observe the UAP's performance and provide feedback and guidance as needed. This can help ensure that the UAP follows the standards of care and respects the client's dignity and preferences.
The other options are not correct because:
A. Asking another UAP to help the oriented may not be appropriate or necessary, as it may interfere with the orientation process and create confusion or conflict.
B. Verifying with the client that the bath was complete and thorough may not be sufficient or reliable, as the client may not be able to assess the quality of care or may not want to complain.
C. Inspecting the client's skin near the end of the bathing procedure may not be timely or comprehensive, as it may miss some aspects of care or some problems that occurred during the bath.
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