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 C
Explanation
Rationale:
A. "I will wait 1 hour after getting up in the morning to have breakfast.": Delaying breakfast may worsen nausea, as symptoms of hyperemesis gravidarum are often worse in the morning. It is recommended to eat a small, dry carbohydrate-rich snack, such as crackers, soon after waking.
B. "I will try to eat balanced meals instead of only foods that appeal to my taste.": While balanced meals are ideal, during hyperemesis gravidarum, the priority is tolerating any nutrition. Clients are encouraged to eat whatever foods they can tolerate, as nutritional intake is often severely limited.
C. “I will eat or drink something every 2 to 3 hours throughout the day": Eating or drinking small amounts frequently helps prevent an empty stomach, which can trigger or worsen nausea and vomiting. This approach improves tolerance and supports hydration and nutrition.
D. “I will eat a low protein snack 30 minutes before going to bed each night.": Protein-rich snacks, not low-protein ones, are better for stabilizing blood glucose levels overnight and may help reduce morning nausea. A high-protein snack before bed is more appropriate.
Correct Answer is C
Explanation
Rationale:
A. Chlorhexidine: Chlorhexidine is primarily used as an antiseptic for skin preparation or wound cleaning. It is not effective for disinfecting surfaces contaminated with bloodborne pathogens such as HIV.
B. Hydrogen peroxide: While hydrogen peroxide has disinfectant properties, it is less effective than bleach against a broad range of viruses, especially in situations involving blood spills where a higher-level disinfectant is recommended.
C. Bleach: A 1:10 dilution of household bleach (sodium hypochlorite) is the recommended solution for disinfecting surfaces contaminated with blood due to its strong virucidal properties. It effectively kills HIV and other bloodborne pathogens on environmental surfaces.
D. Isopropyl alcohol: Isopropyl alcohol has limited effectiveness against organic matter like blood and is not recommended for disinfecting blood-contaminated surfaces. It evaporates quickly and may not provide adequate contact time for complete disinfection.
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