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 {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"}}
Explanation
- Encourage frequent ambulation: Anticipated. Ambulation can help progress labor, unless contraindicated by the healthcare provider.
- Prepare the client for catheterization: Non-essential. There is no current indication for catheterization as the client is voiding adequately and not in active labor.
- Ensure the client maintains a supine position while in bed: Contraindicated. The supine position can cause supine hypotensive syndrome in pregnant clients. A side-lying position is preferred to optimize blood flow.
- Check FHR every 30 min: Anticipated. Regular monitoring of FHR is important to assess fetal well-being during labor.
- Perform a Nitrazine test: Anticipated. Since the client reports fluid leakage, a Nitrazine test can help confirm if the membranes have ruptured.
- Check client's temperature every hour: Non-essential. The client's temperature is stable, and hourly checks are not indicated unless there are signs of infection or the membrane has been ruptured for an extended period.
- Obtain CBC blood sample: Anticipated. A CBC can help identify any underlying issues such as anemia or infection that could affect labor and delivery.
Correct Answer is D
Explanation
A. "I will need to start chemotherapy immediately." is incorrect. Chemotherapy is not always immediately necessary. Treatment depends on follow-up tests and the presence of persistent or malignant disease.
B. "I will need home palliative services after I am discharged from the hospital." is incorrect. Most clients recovering from a molar pregnancy do not require home palliative services unless there are specific complications.
C. "I will need an amniocentesis within 1 month." is incorrect. Amniocentesis is not required for clients recovering from a molar pregnancy.
D. "I will need to attend a support group when I get home." is correct. Support groups are helpful for emotional support and recovery after a molar pregnancy.
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