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
Observe how UAP obtains temperatures.
Choice A rationale:
The PN should first observe how the unlicensed assistive personnel (UAP) obtains temperatures using a tympanic thermometer. This step is essential to determine if there is an error in the technique or if the thermometer is malfunctioning. Correct technique and proper use of equipment are crucial to obtaining accurate and reliable temperature readings.
Choice B rationale:
While returning the thermometer for recalibration might be necessary if the thermometer is indeed faulty, it should not be the first action the PN takes. Observing the UAP's technique will help identify if the issue lies with the equipment or the individual's method.
Choice C rationale:
Demonstrating how to use the equipment might be helpful if the UAP is incorrectly using the thermometer. However, observing the UAP's technique first will help the PN identify if there is a need for retraining or recalibration.
Choice D rationale:
Showing the UAP how to chart temperatures is not the first priority when inconsistent readings are noted. Ensuring the accuracy of temperature measurements is essential for proper patient care and assessment.
Correct Answer is B
Explanation
The correct answer is choice B. Attach the drainage bag to the bed frame.
Choice A rationale:
Measuring the urinary output in the bag is a routine task but does not address the improper placement of the drainage bag. The immediate concern is to ensure the drainage bag is correctly positioned to prevent complications.
Choice B rationale:
Attaching the drainage bag to the bed frame is the correct action. The drainage bag should be kept below the level of the bladder and attached to a non-movable part of the bed to prevent backflow and reduce the risk of infection.
Choice C rationale:
Applying gloves and emptying the drainage bag is not the immediate priority. The drainage bag should not be allowed to overfill, but in this scenario, it is only half-full, so this action is not urgent.
Choice D rationale:
Removing the looped tubing from the bed is important to ensure proper drainage and prevent backflow, but it does not address the incorrect placement of the drainage bag, which is the primary concern in this situation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today