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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The lancet should be used on the outer aspect of the heel, not the inner aspect, to avoid injury to the heel's bone and nerves. Proper technique for heel puncture is critical for successful specimen collection.
B. Warming the newborn’s heel for 5 to 10 minutes before the puncture helps to increase blood flow and ensure a sufficient blood sample for screening tests. This is a recommended practice to improve the effectiveness of the heel stick.
C. Applying an antiseptic to the heel before the puncture is correct practice, but applying it after the specimen is collected is not recommended. It can cause stinging and potentially interfere with the blood sample.
D. After the puncture, the heel should be gently massaged and then covered with a bandage to stop bleeding. Leaving the heel open to the air is not recommended as it can lead to infection or continue bleeding.
Correct Answer is B
Explanation
A. Pruritus is not a common manifestation of hyperemesis gravidarum; it might be associated with liver conditions or other issues.
B. Decreased blood pressure can be an expected manifestation in hyperemesis gravidarum due to dehydration and possible hypovolemia.
C. Hemoglobin of 18 g/dL is higher than normal; hyperemesis gravidarum often leads to decreased hemoglobin due to malnutrition and dehydration.
D. A WBC count of 15,000/mm³ is slightly elevated but not specific for hyperemesis gravidarum; it might be indicative of an infection or inflammation, but it is not a defining characteristic of the condition.
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