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 C
Explanation
A. Blood pressure 156/80 mm Hg is incorrect. While this blood pressure reading is elevated, hypertension is not a typical immediate sign of postpartum hemorrhage. Hemorrhage is more commonly associated with hypotension (low blood pressure) due to fluid loss.
B. Temperature 38.3° C (101° F) is incorrect. A mild fever may be common in the first 24 hours postpartum due to normal inflammatory responses. It is not specifically indicative of postpartum hemorrhage, though a persistent fever could indicate an infection.
C. Respiratory rate 32/min is correct. An increased respiratory rate can be a sign of hypovolemia (due to significant blood loss), which may occur with postpartum hemorrhage. The body compensates for decreased blood volume by increasing the respiratory rate.
D. Apical pulse 66/min is incorrect. A heart rate of 66/min is within normal limits and would not be indicative of postpartum hemorrhage. In fact, a tachycardic (elevated) heart rate is more concerning in the case of hemorrhage as the body tries to compensate for blood loss.
Correct Answer is A
Explanation
A. The lecithin/sphingomyelin (L/S) ratio assesses fetal lung maturity. A higher ratio indicates that the baby's lungs are mature enough to handle breathing air outside the womb, which is the primary purpose of this test.
B. The L/S ratio test does not assess placental function. Placental function is evaluated through other tests, such as Doppler studies or biophysical profiles.
C. The L/S ratio test is not related to Rh incompatibility. Rh incompatibility issues are managed through different assessments, such as the Coombs test and Rh factor screening.
D. The L/S ratio test does not indicate genetic disorders. Genetic disorders are assessed through tests like amniocentesis or chorionic villus sampling, not the L/S ratio.
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