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A nurse is assisting in the care of a group of clients who are postpartum. Which of the following clients should the nurse plan to see first?

A client who has a firm fundus following a vaginal birth and reports continuous perineal pain of 8 on a scale of 0 to 10

A client who is 30 hr postpartum and reports feeling tearful and overwhelmed

A client who is 12 hr postpartum and reports having to urinate frequently

A client who had a cesarean birth yesterday and reports burning incision pain of 5 on a scale of 0 to 10

Answer and Explanation

The Correct Answer is A

Rationale:

A. A client who has a firm fundus following a vaginal birth and reports continuous perineal pain of 8 on a scale of 0 to 10: Although the fundus is firm, severe continuous perineal pain may indicate complications such as hematoma or infection, requiring immediate assessment and intervention to prevent worsening condition.

B. A client who is 30 hr postpartum and reports feeling tearful and overwhelmed: Postpartum emotional lability is common in this timeframe and generally not an immediate safety concern. The nurse should provide support but this client’s condition is not urgent.

C. A client who is 12 hr postpartum and reports having to urinate frequently: Frequent urination postpartum may be due to diuresis or normal bladder function return and is not typically urgent unless accompanied by other signs of infection or retention.

D. A client who had a cesarean birth yesterday and reports burning incision pain of 5 on a scale of 0 to 10: Moderate incision pain is expected after surgery and can be managed with analgesics; it does not require immediate intervention compared to potential perineal complications.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. Tilt the client's head forward during meals: Tilting the head forward, also known as the chin-tuck technique, helps close the airway and reduce the risk of aspiration in clients with dysphagia. This position facilitates safer swallowing by improving bolus control and airway protection.

B. Encourage socialization during meal times: While social interaction is generally beneficial, clients with dysphagia require focused attention during meals to prevent choking or aspiration. Distractions can compromise concentration on swallowing techniques and safety precautions.

C. Elevate the head of the client's bed to 30": Although elevating the head of the bed helps reduce aspiration risk, a 30" elevation is not optimal for swallowing. A 45–90 degree upright position is typically recommended during meals to support safer swallowing mechanics.

D. Provide three large meals per day: Clients with dysphagia benefit more from small, frequent meals to reduce fatigue and lower the risk of aspiration. Large meals can overwhelm their ability to chew and swallow safely, increasing the risk of complications.

A. The client needs strict measurement of intake and output. B. The client develops a postoperative fever. C. The client is experiencing a therapeutic effect from their treatment D. The client needs routine wound care performed.

Correct Answer is B

Explanation

Rationale:

A. The client needs strict measurement of intake and output: This task can be delegated to assistive personnel as it involves routine data collection without complex clinical judgment.

B. The client develops a postoperative fever: A postoperative fever may indicate infection or other complications requiring assessment, clinical judgment, and intervention by a registered nurse.

C. The client is experiencing a therapeutic effect from their treatment: Monitoring expected therapeutic effects is routine and can often be overseen by licensed practical nurses or assistive personnel, depending on policy.

D. The client needs routine wound care performed: Routine wound care is generally a delegated nursing task that does not require the advanced assessment or clinical decision-making of an RN unless complications arise.

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A nurse is assisting in the care of a group of clients who are postpartum. Which of the following clients should the nurse plan to see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has dysphagia. Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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