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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Magnesium sulfate is used to manage preeclampsia or prevent preterm labor, not for treating an ectopic pregnancy. It does not address the issue of an unruptured ectopic pregnancy.
B. Methotrexate is a medication used to treat an unruptured ectopic pregnancy by dissolving the ectopic tissue and allowing it to be reabsorbed by the body. It is a first-line treatment for early, unruptured ectopic pregnancies to prevent complications.
C. Calcium gluconate is used to treat hypocalcemia or to counteract the effects of magnesium sulfate in preeclampsia, not for ectopic pregnancies. It is not relevant to the management of an unruptured ectopic pregnancy.
D. Terbutaline is used to manage preterm labor by relaxing uterine contractions. It does not address the treatment of an ectopic pregnancy and is not indicated for this condition.
Correct Answer is C
Explanation
A. Uterine contractions lasting 30 to 45 seconds
Rationale: Uterine contractions lasting 30 to 45 seconds are within the expected range for the latent phase of labor. This duration indicates that contractions are occurring but are not too frequent or too prolonged, which is typical for this stage of labor.
B. Uterine contractions every 6 min
Rationale: Contractions every 6 minutes are also typical for the latent phase of labor, where contractions are still becoming more frequent as labor progresses. This frequency does not suggest fetal distress or a significant risk to the fetus.
C. Recurrent variable deceleration of the FHR
Rationale: Recurrent variable decelerations in fetal heart rate (FHR) indicate that the fetus might be experiencing umbilical cord compression. This finding suggests a risk to the fetus, as it can be associated with reduced oxygenation and may require intervention to manage labor and optimize fetal well-being.
D. Moderate variability of the FHR
Rationale: Moderate variability in FHR is an indication of a well-oxygenated fetus and a healthy autonomic nervous system. This is a reassuring sign of fetal well-being rather than a risk.
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