A nurse is caring for an older adult client in the PACU following general anesthesia. Which of the following findings should the nurse report to the provider?
Urine output 120 mL in 4 hr
Systolic blood pressure 12 mm Hg lower than the preoperative level
Audible stridor
Normal sinus rhythm with an occasional premature ventricular contraction
The Correct Answer is C
Rationale:
A. Urine output of 120 mL in 4 hours is within acceptable limits, especially following anesthesia. Normal output can vary, but 30 mL/hr is often used as a guideline.
B. A systolic blood pressure that is only 12 mm Hg lower than preoperative levels may be concerning, but it does not necessarily require immediate reporting unless other symptoms are present.
C. Audible stridor is a sign of airway obstruction or severe respiratory distress and requires immediate medical attention. It should always be reported to the provider.
D. An occasional premature ventricular contraction (PVC) can be common postoperatively and may not necessitate reporting unless accompanied by significant symptoms or changes in hemodynamic status.
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Correct Answer is C
Explanation
Rationale:
A. Reporting suspected child maltreatment is a legal and ethical responsibility of the nurse; this action is appropriate and does not require intervention.
B. Notifying the health department about a client's diagnosis of chlamydia is a legal requirement, as it is a reportable disease, so this action is appropriate.
C. Sharing a client’s diagnosis with a hospital chaplain without the client's consent could violate the client's confidentiality and requires intervention.
D. Informing the provider about a client's suicide plan is a critical action for patient safety and does not require intervention.
Correct Answer is B
Explanation
Rationale:
A. While assessing pain level is important for comfort management, it is not the highest priority in the immediate postpartum period.
B. The amount of vaginal bleeding is critical to assess during the fourth stage of labor to identify potential postpartum hemorrhage, especially with oxytocin administration.
C. Although urinary output is important to monitor for bladder distension, it does not take precedence over bleeding assessment.
D. Fundal height assessment is necessary to ensure the uterus is contracting effectively, but again, it is secondary to monitoring for bleeding.