A nurse in a postpartum unit is caring for several clients. After receiving a change-of-shift report, which of the following clients should the nurse assess first?
A client who is 2 days postpartum and whose fundus is 2 fingerbreadths below the umbilicus
A client who is 1 day postpartum and has not voided in 8 hr
A client who is 3 days postpartum and has not had a bowel movement since prior to admission
A client who is 4 days postpartum and has lochia serosa
The Correct Answer is B
A. A fundal height of 2 fingerbreadths below the umbilicus in a client who is 2 days postpartum is within the expected range for that time frame and does not require immediate assessment.
B. A client who is 1 day postpartum and has not voided in 8 hours may be at risk for urinary retention, which can lead to complications such as bladder distension or urinary tract infection. Prompt assessment and intervention are needed.
C. Not having a bowel movement since prior to admission is not an urgent concern in the
immediate postpartum period, especially if the client is otherwise stable and not experiencing discomfort or other symptoms.
D. Lochia serosa, which is the normal vaginal discharge that occurs 3 to 10 days postpartum, is not an urgent concern and does not require immediate assessment.
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Correct Answer is C
Explanation
A. Performing another internal exam is not the priority at this moment. The priority is assessing fetal well-being.
B. Notifying the client's provider may be necessary, but it is not the immediate priority.
C. Checking the fetal heart rate (FHR) is the priority action to assess fetal well-being after the observed fluid gush, as it could indicate rupture of membranes and potentially fetal distress.
D. Obtaining a pH test of the fluid can be done later for confirmation of rupture of membranes but is not the immediate priority compared to assessing fetal well-being.
Correct Answer is C
Explanation
A. Providing guidance on incentive spirometry requires specialized knowledge and skill that should be provided by a licensed healthcare provider, such as a nurse.
B. A client who had a myocardial infarction 3 days ago and reports chest discomfort requires ongoing assessment and monitoring by a licensed healthcare provider, such as a nurse, due to the potential for cardiac complications.
C. Assisting a client who had a stroke 2 days ago and needs help toileting is a task that can be safely delegated to an assistive personnel, as long as the client's condition is stable and the assistive personnel has been trained in providing basic care.
D. Providing a drink to a client who has awoken following a bronchoscopy may require assessment and monitoring for potential complications, such as aspiration or respiratory distress, which should be provided by a licensed healthcare provider, such as a nurse.
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