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. Beefy, red tongue: A beefy, red tongue is typically associated with scarlet fever, not pertussis. It results from the streptococcal infection and accompanying inflammatory response, which is unrelated to the bacterial cause and symptom pattern of pertussis.
B. Productive cough with thick mucous: Pertussis, or whooping cough, usually causes a paroxysmal, dry, hacking cough followed by a characteristic "whooping" sound on inspiration. It is not commonly associated with a productive cough containing thick mucus, especially in early and peak stages.
C. Facial erythema: Facial erythema can occur during severe coughing fits in children with pertussis due to the forceful and prolonged nature of coughing episodes. The increased intrathoracic pressure during coughing may lead to flushing or redness of the face.
D. Koplik spots: Koplik spots are small, bluish-white lesions on the buccal mucosa and are an early sign of measles, not pertussis. They are not present in bacterial infections like Bordetella pertussis, which affects the respiratory tract.
Correct Answer is D
Explanation
Rationale:
A. A child who was conceived by in vitro fertilization: Children conceived through IVF are typically highly desired and planned for, and families may invest significant emotional and financial resources into their care. This background generally reduces rather than increases the risk of maltreatment.
B. A toddler who has atopic dermatitis: Although chronic conditions can be stressful for caregivers, atopic dermatitis is relatively common and manageable. It does not significantly increase the risk of child abuse or neglect compared to more severe or demanding conditions.
C. An only child: Being an only child does not inherently increase the risk for maltreatment. Risk factors for abuse are more closely associated with caregiver stress, socioeconomic status, substance use, and the presence of physical or cognitive impairments in the child.
D. A school-age child who has cerebral palsy: Children with disabilities like cerebral palsy are at higher risk for maltreatment due to the physical, emotional, and financial stress their care may place on caregivers. These children often require more supervision and support, which can lead to frustration or neglect in high-risk environments.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.