The nurse is caring for a postpartum client who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider?
a. Pulse rate of 50
b. Temperature of 38° C (100.4° F)
c. Firm fundus, but excessive lochia
d. Lightheaded when moving from a lying to standing position
ANS: C
Excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal. The health care provider must be notified so that lacerations can be located and repaired. Bradycardia, defined as a pulse rate of 40 to 50 beats per minute (bpm), may occur as the large amount of blood that returns to the central circulation after birth of the placenta. A temperature of up to 38° C (100.4° F) is common during the first 24 hours after childbirth and may be caused by dehydration or normal postpartum leukocytosis. The resulting engorgement of abdominal blood vessels contributes to a rapid fall in BP of 15 to 20 mm Hg systolic when the woman moves from a recumbent to a sitting position. This change causes mothers to feel dizzy or lightheaded or to faint when they stand.
You might also like to view...
What is the most appropriate statement from the nurse when coaching the laboring woman with a fully dilated cervix to push?
a. "At the beginning of a contraction, hold your breath and push for 10 seconds." b. "Take a deep breath and push between contractions." c. "Begin pushing when a contraction starts and continue for the duration of the contraction." d. "At the beginning of a contraction, take two deep breaths and push with the second exhalation."
The nurse is caring for a patient who is in the recovery room following the implantation of an ICD. The patient has developed ventricular tachycardia (VT). What should the nurse assess and document?
A) ECG to compare time of onset of VT and onset of device's shock B) ECG so physician can see what type of dysrhythmia the patient has C) Patient's level of consciousness (LOC) at the time of the dysrhythmia D) Patient's activity at time of dysrhythmia
The nurse informs a group of young adults that the leading cause of death in their age group is:
a. diabetes. b. accidents. c. hypertension. d. testicular cancer.
In which situation would a dilation and curettage (D&C) be indicated?
a. Complete abortion at 8 weeks b. Incomplete abortion at 16 weeks c. Threatened abortion at 6 weeks d. Incomplete abortion at 10 weeks