A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Which of the following assessments is the nurse's priority?
Pain Level
Amount of vaginal bleeding
Amount of urinary output
Fundal Height
The Correct Answer is B
A. While assessing pain level is important for comfort management, it is not the highest priority in the immediate postpartum period.
B. The amount of vaginal bleeding is critical to assess during the fourth stage of labor to identify potential postpartum hemorrhage, especially with oxytocin administration.
C. Although urinary output is important to monitor for bladder distension, it does not take precedence over bleeding assessment.
D. Fundal height assessment is necessary to ensure the uterus is contracting effectively, but again, it is secondary to monitoring for bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Muscle rigidity is not a typical manifestation of digoxin toxicity; it is more commonly associated with other conditions or medications.
B. Constipation can occur but is not a primary sign of digoxin toxicity.
C. Nausea is a common early sign of digoxin toxicity and should be included in the teaching. Other symptoms may include vomiting, visual disturbances, and confusion.
D. Wheezing is not associated with digoxin toxicity; it may suggest respiratory issues or an allergic reaction.
Correct Answer is A
Explanation
A. This response validates the client's feelings and opens the door for further conversation without judgment, encouraging the client to express more of their thoughts.
B. While this statement acknowledges the client's feelings, it may seem dismissive or minimize the depth of the client's distress.
C. Telling the client that many people experience similar feelings can invalidate the uniqueness of their grief and may discourage them from sharing more.
D. Asking "Why" may sound accusatory and could make the client feel defensive or misunderstood.
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