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

Answer and Explanation

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 D

Explanation

A. Insisting the client use direct eye contact may be intimidating or uncomfortable for the client, especially in a mental health setting where individuals may have varying levels of comfort with eye contact.

B. Seating the client at such a distance may create a physical barrier and hinder effective communication between the nurse and the client.

C. Positioning the client's chair between the nurse's chair and the door may make the client feel trapped or uncomfortable, especially during a sensitive interview.

D. Leaning in slightly when speaking to the client demonstrates attentiveness and facilitates a sense of closeness and engagement in the conversation, which can help build rapport and trust.

A. Metoprolol B. Clopidogrel C. Metformin D. Digoxin

Correct Answer is C

Explanation

A. Metoprolol is a beta-blocker used to treat hypertension and other cardiovascular conditions.

While it may be important for the provider to be aware of all medications, it is not the priority to report in this scenario.

B. Clopidogrel is an antiplatelet medication used to prevent blood clots in individuals at risk for cardiovascular events. While it may have implications for the procedure, it is not the priority to report in this scenario.

C. Metformin is an oral antidiabetic medication commonly used to treat type 2 diabetes. It is

important to report because there may be specific considerations regarding its use in the context of a colonoscopy, such as the risk of lactic acidosis.

D. Digoxin is a medication used to treat heart failure and certain arrhythmias. While it may have implications for the procedure, it is not the priority to report in this scenario.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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