The nurse is assisting to gather data from a high-risk postpartum client who delivered 60 hours ago. The nurse will notify the RN if which of the
... [Show More] following is found?
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Breasts are enlarged and firm to touch.
3+ reflexes.
Client is tearful one minute and laughing the next.
n 0.4
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The nurse is assisting with the care for a client who was diagnosed with pre-eclampsia during her third trimester and received intravenous magnesium sulfate during labor and until 24 hours postpartum. The client is now 48 hours postpartum and the nurse notes which of the following goals on the clients' electronic medical record?
(Select all that apply.)
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Question options:
Reflexes will remain at 2+ or above for at least 48 hours postpartum.
Proteinuria will decline prior to discharge.
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Rationale: The client's blood pressure should return to pre-labor level within an hour of delivery, and should be monitored frequently (at least hourly) if it do take time to subside, but should begin to decline by time of discharge. Reflexes should be less than 2+, and she should not have two beats of clonus with dors begin to subside within the first 12-24 hours, and weight should decline as a result.
Cognitive Level: Analyzing
Nursing Process: Planning
Client Need: Physiological Integrity
Rationale: The client's blood pressure should return to pre-labor level within an hour of delivery, and should be monitored frequently (at least hourly) if it do take time to subside, but should begin to decline by time of discharge. Reflexes should be less than 2+, and she should not have two beats of clonus with dors begin to subside within the first 12-24 hours, and weight should decline as a result.
Cognitive Level: Analyzing
Nursing Process: Planning
Client Need: Physiological Integrity
Rationale: The client's blood pressure should return to pre-labor level within an hour of delivery, and should be monitored frequently (at least hourly) if it do take time to subside, but should begin to decline by time of discharge. Reflexes should be less than 2+, and she should not have two beats of clonus with dors begin to subside within the first 12-24 hours, and weight should decline as a result.
Cognitive Level: Analyzing
Nursing Process: Planning
Client Need: Physiological Integrity
3 0 / 1 point
The nurse receives a telephone call from a woman who delivered her baby three days ago and now reports foul-smelling lochia and a temperature of 101.2°F. The nurse instructs the new mother to:
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