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 D
Explanation
A. Detaching the needle from the syringe before discarding it increases the risk of needle-stick injuries. Needles should be disposed of as one unit to minimize the risk of injury.
B. Broken glass should be disposed of in a puncture-proof container to prevent injuries. Placing it directly in a wastebasket increases the risk of puncture injuries to individuals handling the waste.
C. Recapping needles increases the risk of needle-stick injuries. Needles should not be recapped after use unless there is no safer alternative. Instead, they should be disposed of as one unit.
D. Lancets, needles, and other sharp objects should be placed in puncture-proof containers immediately after use to prevent injuries. This practice helps ensure the safety of healthcare workers and others who handle waste.
Correct Answer is D
Explanation
A. Diminished bowel sounds are not typically indicative of fluid overload. They may suggest decreased gastrointestinal motility, but this finding alone does not specifically indicate fluid overload.
B. Bradycardia is not typically associated with fluid overload. Instead, tachycardia may occur as the body attempts to compensate for decreased cardiac output.
C. Hypotension may occur with fluid overload in severe cases, but it is not a consistent or specific finding. Other signs, such as bounding pulses, are more indicative of fluid overload.
D. Bounding pulses, or strong and forceful arterial pulses, can be a sign of fluid overload due to increased blood volume. This finding may be observed in clients receiving excessive enteral feedings or intravenous fluids.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.