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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The examination light of the ophthalmoscope should be directed toward the client's eye, not the client's face.
B. When examining the left eye, the nurse should stand on the right side of the client to facilitate proper alignment of the ophthalmoscope with the client's eye.
C. Dimming the lights in the room may improve visualization of the client's internal eye
structures, but it is not typically necessary for ophthalmoscopic examination and may hinder the nurse's ability to assess the client effectively.
D. Placing the ophthalmoscope directly against the client's forehead would not facilitate proper examination of the internal eye structures and may cause discomfort to the client.
Correct Answer is D
Explanation
A. Administer an antitoxin: There is no specific antitoxin available for anthrax. Treatment primarily involves antibiotics and supportive care.
B. Quarantine the client: Quarantine may not be necessary unless the client is confirmed to have an active infection or poses a risk of spreading the disease to others.
C. Monitor the client for a productive cough: While respiratory symptoms can occur in inhalation anthrax, monitoring for a productive cough alone may not be sufficient for management.
D. Begin prophylactic treatment with ciprofloxacin: Prophylactic antibiotic treatment with ciprofloxacin or doxycycline is recommended following exposure to anthrax to prevent the development of the disease.
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