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 A

Explanation

A. Visible contusions on all four extremities may indicate physical abuse, especially in the context of being brought to the emergency department by a family member. Reporting the

incident to Adult Protective Services is essential to ensure the safety and well-being of the client.

B. Interviewing the client with his adult child present may not be appropriate if there are concerns about potential abuse or coercion.

C. Forcing the client to answer every assessment question may not be appropriate if the client is in distress or unable to communicate freely.

D. Advising the client to consult a social worker may be appropriate, but reporting suspected abuse to Adult Protective Services is the priority action in this situation.

A. Notify the facility operator. B. Close the fire doors on the unit. C. Turn off oxygen sources. D. Put out the fire with the appropriate extinguisher.

Correct Answer is C

Explanation

A. Notifying the facility operator is important, but it is not the immediate priority when there is a fire endangering the client's safety.

B. While closing fire doors can help contain the fire, it is not the priority action after ensuring the client's immediate safety.

C. Turning off oxygen sources is crucial because oxygen can fuel the fire and cause it to spread rapidly. This action helps prevent the fire from worsening.

D. Putting out the fire with the appropriate extinguisher is important, but it comes after ensuring the fire's fuel source is cut off to prevent further escalation of the fire.

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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

A nurse is assessing a client who was brought to the emergency department by his adult child. The client has visible contusions on all four extremities. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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