Nokea
Nurses' Notes: Breasts soft, nipples intact, uterus firm at 0700, soft with lateral deviation at 1100, large lochia rubra at 1100, episiotomy site with mild edema/ecchymosis, pain 2-3/10, able to void, DTR 1+, 2+ peripheral edema. Vital Signs: Temp 36.2-37.2°C, HR 80-85/min, RR 16-18/min, BP 136/82-86 mm Hg, O2 sat 99-100%.
Select the findings that require immediate follow-up.
- A. Peripheral edema 2+ bilateral lower extremities
- B. Pain rating of 3 on a scale of 0 to 10
- C. Large amount of lochia rubra
- D. Deep tendon reflexes 1+
- E. Blood pressure 136/86 mm Hg
- F. Uterine tone soft
Correct Answer: C,F
Rationale: Large lochia rubra, soft uterus, and lateral deviation suggest postpartum hemorrhage risk, requiring immediate intervention like fundal massage and bladder assessment.
You may also like to solve these questions
A nurse is caring for a client who is pregnant and has a vaginal culture that is positive for chlamydia.
Which of the following medications should the nurse plan to administer?
- A. Amoxicillin
- B. Acyclovir
- C. Metronidazole
- D. Tetracycline
Correct Answer: A
Rationale: Amoxicillin is safe and effective for treating chlamydia during pregnancy, posing no known fetal risks.
Medical History: 26-year-old primigravida at 28 weeks, obese, no hypertension or diabetes history, presents with elevated blood pressure, peripheral edema, headaches. Physical Examination: Alert, oriented, 3+ deep tendon reflexes, +2 pitting edema, FHR 140/min with moderate variability. Diagnostic Results: Hgb 10 g/dL, Hct 35%, Platelet count 95,000/mm3, AST 200 units/L, ALT 25 units/L, Total bilirubin 1.8 mg/dL, Urine 2+ protein. Vital Signs: BP 158/100 mm Hg (0900), 162/110 mm Hg (1000), HR 90-95/min, RR 16-20/min, Temp 37°C, O2 sat 96-98%.
The nurse should first address the client's ___ followed by the client's ___
- A. Blood pressure; Platelet count
- B. Respiratory rate; Hematocrit
- C. Deep tendon reflexes; Peripheral edema
- D. Platelet count; Hematocrit
Correct Answer: A
Rationale: Severe hypertension (162/110 mm Hg) risks stroke and eclampsia, requiring immediate antihypertensive treatment, followed by addressing low platelet count (95,000/mm³) indicating HELLP syndrome and bleeding risk.
A nurse is preparing to administer metronidazole 2 g PO. The amount available is 500 mg tablets.
How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)
Correct Answer: 4 tablets
Rationale: 2 g = 2000 mg; 2000 mg / 500 mg/tablet = 4 tablets.
A nurse is reinforcing discharge instructions about breastfeeding with a client.
Which of the following statements should the nurse make?
- A. You should feed your baby six times a day.
- B. You should wake your baby at least every 6 hours at night for feedings.
- C. You should recognize that your baby sucking on his hands is a hunger cue.
- D. You should feed your baby for 10 minutes on each breast.
Correct Answer: C
Rationale: Sucking on hands is an early hunger cue, aiding effective feeding by recognizing the baby's needs.
Vital Signs: Blood pressure 130/70 mm Hg, Temperature 38.6° C (101.5° F), Respiratory rate 18/min, Heart rate 102/min, Oxygen saturation 98% on room air. History and Physical: Delivered at 37 weeks of gestation, Routine prenatal care, Iron-deficiency anemia, Rubella immune, Shellfish and penicillin allergy. Current Diagnosis: Mastitis. Laboratory Test Results: Blood type O+, Creatinine 0.8 mg/dL, WBC count 9,500/mm3. Medication Administration Record: Ibuprofen 800 mg PO every 6 hr PRN pain, Doxycycline 100 mg PO every 12 hr, Ferrous sulfate 325 mg PO twice daily, Folic acid 0.5 mg PO once daily, Bisacodyl 10 mg PO once daily, Rho(D) immune globulin 300 mcg IM x1. A nurse is preparing to assist with the administration of medications to a client who is 72 hr postpartum following a caesarean birth.
Which of the following medications requires clarification prior to administration? The nurse should clarify the prescription for ___ because ___
- A. Rho(D) immune globulin; of the client's blood type.
- B. Ibuprofen; of the client's WBC count.
- C. Doxycycline; of the client's heart rate.
- D. Bisacodyl; of the client's blood type.
Correct Answer: A
Rationale: Rh (D) immune globulin is given to Rh-negative clients to prevent Rh sensitization. Since the client is O+ (Rh-positive), there is no risk of Rh incompatibility, making this medication unnecessary.