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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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Correct Answer is D

Explanation

Rationale:

A. Use touch to convey acceptance: Using touch with clients who are actively hallucinating can be misinterpreted and may provoke fear or aggression. Maintaining a safe physical distance and using verbal reassurance is more appropriate during episodes of hallucination.

B. Avoid attempting to distract the client away from the hallucination: Distraction techniques are often helpful in managing hallucinations. Encouraging the client to engage in a different activity or conversation can help shift their focus away from distressing perceptual disturbances.

C. Encourage group activities: Group settings may increase anxiety or overstimulation for a client who is actively hallucinating. Individualized, low-stimulation environments are more therapeutic during acute symptoms.

D. Provide low lighting in the client's room: A calm, low-stimulation environment including dim lighting can reduce sensory overload and help the client feel more secure. Low lighting may also help minimize misinterpretation of visual stimuli that could feed into hallucinations.

A. 300 mg PO od B. 3.0 mg PO gd C. 10.000 units IV dally D. 05 mL IM daily

Correct Answer is A

Explanation

Rationale:

A. 300 mg PO od: The dose is written clearly with no trailing zeros, and “od” (once daily) is acceptable though “daily” is preferred for clarity. This entry minimizes risk of misinterpretation and decimal errors.

B. 3.0 mg PO gd: Using a trailing zero (3.0 mg) increases the risk of a tenfold dosing error if the decimal point is missed. Also, “gd” is an incorrect abbreviation; “daily” or “once daily” should be used.

C. 10.000 units IV dally: Writing “10.000” with multiple trailing zeros is dangerous because the decimal point might be overlooked, causing a ten-thousand-fold error. Also, “dally” is a misspelling of “daily.”

D. 05 mL IM daily: Leading zeros before whole numbers (05 mL) are unnecessary and can cause confusion. The correct notation is “5 mL.” Leading zeros should only be used before decimals less than one (e.g., 0.5 mL).

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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

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Correct Answer is A

Explanation

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