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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. "Notify your provider if you experience muscle weakness." - Muscle weakness can be a sign of digoxin toxicity and should be reported to the provider immediately.
B. "Report a weight gain of one-half pound per day." - While weight gain can indicate fluid retention, it is not a specific symptom of digoxin toxicity.
C. "Expect this medication to increase your blood pressure." - Digoxin is not typically associated with increasing blood pressure.
D. "You will need to take a diuretic while taking this medication." - Diuretics are not typically required with digoxin unless there are specific indications for their use.
Correct Answer is C
Explanation
A. Tilted head position facilitates drainage into the nasolacrimal duct, not necessarily into the eye.
B. Washing away exudate is not necessary before administering eye drops.
C. Using aseptic technique to drop medication into the conjunctival sac ensures proper delivery of the medication to the eye.
D. Dropping medication onto the cornea can cause discomfort and may not effectively reach the eye.
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