A client is admitted to the postpartum unit and tells the nurse she had rheumatic fever as a child, which resulted in some "heart damage." The nurse knows that this client is at particular risk for developing heart failure during the immediate postpartum period. Based on this client's history, which nursing problem has the highest priority?
Sleep deprivation.
Fluid volume excess
Nausea and vomiting
Risk for infection.
The Correct Answer is B
A. Sleep deprivation:
While sleep is important for overall well-being, it may not be the top priority in this case. Fluid volume excess, given the client's cardiac history, poses a more immediate threat to health.
B. Fluid volume excess:
Clients with heart damage are prone to heart failure, and managing fluid balance is crucial. Excess fluid can worsen cardiac function, making this the priority concern.
C. Nausea and vomiting:
While nausea and vomiting are significant concerns, they might not be as directly related to the client's cardiac history as fluid volume excess. However, if severe, it could contribute to fluid imbalance.
D. Risk for infection:
Infection is a concern for postpartum clients, but in this case, the client's history of rheumatic fever and heart damage takes precedence. The priority is to prevent complications related to heart failure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Calcium:
Calcium is essential for the development of fetal bones and teeth, but it is not specifically linked to preventing neural tube defects like anencephaly.
Iron:
Iron is crucial for preventing anemia in pregnancy, supporting increased blood volume. However, it is not directly associated with preventing neural tube defects.
Folic acid:
Folic acid is vital for preventing neural tube defects, including anencephaly. It's recommended for women of childbearing age and especially during the early stages of pregnancy.
Vitamin D:
Vitamin D is important for bone health, but its primary function is not directly related to preventing neural tube defects like anencephaly.
Correct Answer is C
Explanation
A. Notify the healthcare provider of the complaint: While it's important for the healthcare provider to be aware of any changes or symptoms the client is experiencing, the described discharge is commonly associated with normal physiological changes in pregnancy.
B. Recommend an over-the-counter yeast medication: The characteristics of the discharge described (white, thin, and watery) are not typical of a yeast infection. Using over-the-counter medications without proper assessment can lead to unnecessary treatment.
C. Inform her that this is a normal physiological change: This is the most appropriate action. Increased vaginal discharge, often described as leukorrhea, is a common and normal change during pregnancy. It's generally thin, white, and watery.
D. Prepare the client for a sterile speculum exam: A sterile speculum exam may be indicated if there are other concerning symptoms or if the discharge changes in color, consistency, or if there is associated itching or foul odor. However, based on the information provided, it's not the first-line action.
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