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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. "I should be able to follow my normal routine after the staples are removed from my incision.” Normal activities should be resumed gradually; simply removing staples does not mean the incision and abdominal muscles have fully healed.
B. "I will ask my partner to perform household chores until my incision is healed." Delegating strenuous tasks supports proper healing and prevents strain on the incision site, reflecting appropriate understanding of postpartum activity restrictions.
C. "I will wait 4 to 6 weeks to perform kegel exercises." Kegel exercises can usually begin soon after delivery to strengthen pelvic floor muscles and are not delayed for several weeks unless specifically advised.
D. "I will maintain modified bed rest for the first 48 to 72 hours at home." While initial rest is important, prolonged bed rest can increase the risk of complications like blood clots. Gradual ambulation is encouraged to promote circulation and recovery.
Correct Answer is A
Explanation
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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