A nurse has just received change-of-shift report about four clients who are postpartum. Which of the following clients should the nurse plan to see first?
A client whose newborn is having difficulty latching-on
A client who received magnesium sulfate during labor
A client who has a history of oligohydramnios
A client whose labor lasted for 6 hr
The Correct Answer is B
A. A client whose newborn is having difficulty latching-on should be addressed, but this issue is not an immediate postpartum emergency. It is important but does not require urgent intervention compared to potential complications from magnesium sulfate.
B. A client who received magnesium sulfate during labor should be seen first because magnesium sulfate can cause significant side effects like respiratory depression, decreased reflexes, and altered mental status. These effects require close monitoring to prevent severe complications.
C. A client who has a history of oligohydramnios requires monitoring but this history does not necessarily indicate an immediate postpartum issue requiring urgent assessment at this time.
D. A client whose labor lasted for 6 hr does not have an immediate concern solely based on labor duration. While it is relevant, it does not indicate an urgent need for assessment compared to the effects of magnesium sulfate.
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Related Questions
Correct Answer is C
Explanation
A. The deltoid muscle is not recommended for newborns; the vastus lateralis is the preferred site for intramuscular injections.
B. A 25-gauge needle is an appropriate size for newborn injections, but needle choice alone is not the priority action for this specific medication administration.
C. Phytonadione (Vitamin K) is typically administered within the first 6 to 12 hours after birth, allowing time for initial stabilization and bonding before injection, while still preventing vitamin K deficiency bleeding.
D. The mother’s Rh factor is unrelated to vitamin K administration; it is only assessed when considering the need for Rho(D) immune globulin.
Correct Answer is C
Explanation
A. Experiencing burning during urination is not a normal physiological change during pregnancy and could indicate a urinary tract infection. It is important to report this symptom to a healthcare provider for evaluation and appropriate management.
B. The dark line in the middle of the abdomen, known as the linea nigra, is a common and normal physiological change during pregnancy due to hormonal effects, not an indication of infection. This statement reflects a misunderstanding of normal pregnancy changes.
C. Developing discoloration on the cheeks, often referred to as the "mask of pregnancy" or melasma, is a common and expected physiological change due to hormonal fluctuations. This statement shows that the client understands a normal aspect of pregnancy.
D. Swelling of the fingers and face is not a typical or expected change during pregnancy and could indicate a serious condition such as preeclampsia. While mild swelling of the ankles and feet can be normal, swelling in these areas should be evaluated by a healthcare provider.
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