A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?

Fundus at level of umbilicus

Saturated perineal pad in 30 min

Approximated edges of episiotomy

Deep tendon reflexes 4+

Answer and Explanation

The Correct Answer is D

A. Fundus is at level of the umbilicus is well contracted and therefore, not of concern.

B.   A saturated perineal pad in 15 min or less can indicate excessive bleeding.
C.   Approximated edges of episiotomy indicate proper wound repair and therefore, not of concern.
D.   Deep Tendon reflexes 4+ -4+ are hyperactive and indicate the client is at greatest risk for preeclampsia and seizures; this is the priority.

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Correct Answer is B

Explanation

Rationale he priority action in this situation is to ensure the newborn's airway is clear to maintain adequate oxygenation. Secretions bubbling out of the newborn's nose and mouth indicate the

presence of mucus or amniotic fluid that needs to be cleared to prevent airway obstruction and ensure proper breathing.

A. "If you want me to, I can tell your parents for you." B. "You seem scared to talk to your parents." C. "Your parents will have to be told why you are being admitted." D. "Give your parents a chance; they'll understand."

Correct Answer is B

Explanation

A. This response does not respect the client's autonomy and right to confidentiality.

B. This response acknowledges the client's feelings and opens up the opportunity for further discussion.
C. While it's important for parents to be informed about their child's health condition, especially if the adolescent is a minor, this response may escalate the client's anxiety and fear about disclosing their infection to their parents.
D. This response minimizes the client's concerns and may not accurately reflect the complexity of their situation.

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A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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