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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Related Questions
Correct Answer is C
Explanation
A. Wearing an N95 respiratory mask is not typically required for routine care of a toddler with respiratory syncytial virus unless performing procedures that generate aerosols.
B. Negative pressure rooms are generally reserved for patients with airborne infections like
tuberculosis; respiratory syncytial virus does not typically require isolation in a negative pressure room.
C. Using a designated stethoscope helps prevent the spread of infection to other patients by avoiding cross-contamination.
D. Removing the disposable gown after leaving the toddler's room is appropriate for maintaining infection control but is not specific to caring for a toddler with respiratory syncytial virus.
Correct Answer is D
Explanation
A. The provider is not required to notify the client's employer about the admission to a mental health facility. This information is protected under confidentiality laws and regulations.
B. While the client may be strongly encouraged to take prescribed medications, they cannot be forced to do so without consent, especially if they are competent to make their own decisions.
C. Electroconvulsive therapy (ECT) typically requires informed consent from the patient or their legal representative, even in an involuntary admission scenario. Therefore, it is incorrect to state that ECT can be performed without consent.
D. If the client poses a risk of harm to themselves or others, the provider can prescribe restraints as a safety measure. This statement is correct and aligns with safety protocols in mental health facilities.
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