A charge nurse is recommending postpartum clients for discharge following a local disaster. Which of the following clients should the nurse recommend for discharge first?
A client who had an emergency cesarean birth 1 day ago
A client who had a precipitous birth 36 hr ago and has a second-degree perineal laceration
A client who has preeclampsia and a blood pressure of 166/110 mm Hg
A client who received 2 units of packed RBCs 6 hr ago for a postpartum hemorrhage
The Correct Answer is B
A. A client 1 day post-cesarean birth is still at risk for postoperative complications (e.g., infection, bleeding, pain, immobility). This client requires ongoing hospital monitoring.
B. A client who delivered vaginally 36 hours ago and has only a second-degree laceration is generally stable and can safely be discharged home with proper instructions for perineal care.
C. The client with preeclampsia and severe hypertension (166/110 mm Hg) is at high risk for seizures, stroke, and organ complications. This client must remain hospitalized for stabilization and management.
D. A client recently transfused after postpartum hemorrhage needs continued monitoring for recurrent bleeding and transfusion reactions. Discharging this client would be unsafe.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
The first action the nurse should take isevaluating the fetal heart rate tracing,followed by administering labetalol IV.
Rationale forCorrect Answers:
Evaluating the fetal heart rate tracing first is the priority because the client is at 31 weeks of gestation with severe preeclampsia and reported decreased fetal movement. Fetal assessment is time-sensitive; identifying any signs of fetal distress is critical to prevent hypoxia or other complications.
Administering labetalol IV is the next priority to manage the client’s severe hypertension (BP 166/110 mm Hg), which places both mother and fetus at risk for complications such as stroke, placental abruption, or fetal compromise.
Rationale for Incorrect options:
Administering acetaminophen PO addresses maternal headache but does not prevent immediate maternal or fetal complications, so it is lower priority.
Obtaining a 24-hour urine collection, betamethasone, and lactated Ringer’s are important interventions but are secondary to assessing fetal status and stabilizing maternal blood pressure.
Correct Answer is A
Explanation
Rationale:
A. The nurse’s role as a witness confirms that the client signed the consent form voluntarily, without coercion, and was competent at the time of signing. This verifies that the client’s consent was given freely.
B. The client retains the right to refuse or withdraw consent at any time before the procedure begins, even after signing the consent form.
C. The surgeon, not the nurse, is responsible for explaining the procedure, including its risks, benefits, and alternatives.
D. The nurse does not provide detailed explanations of the surgical procedure; doing so could lead to misinformation and legal liability. The nurse only verifies that the provider has fulfilled the informed consent process and that the client signed voluntarily.
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