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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Decreased heart rate is not typical; children with Kawasaki disease often experience tachycardia.

B. Peeling of the soles of the feet is more commonly observed in the convalescent phase of Kawasaki disease rather than the acute phase.

C. Pain in weight-bearing joints can occur in Kawasaki disease but is not the hallmark symptom during the acute phase.

D. Fever unresponsive to antipyretics is a classic finding in the acute phase of Kawasaki disease, indicating ongoing inflammation and a need for further intervention.

A. Assess the client's IV site every 8 hr. B. Check the client's WBC count every 48 hr. C. Monitor the client's mouth every 8 hr. D. Change the client's tubing every 48 hr.

Correct Answer is A

Explanation

A. Assessing the client's IV site every 8 hours is appropriate to prevent complications such as infection or infiltration, especially in an immunocompromised client.

B. Checking the client's WBC count every 48 hours is insufficient; it should be monitored more frequently due to the client's immunocompromised state.

C. Monitoring the client's mouth every 8 hours is necessary, but not as critical as regular IV site assessments.

D. Changing the client's tubing every 48 hours may not be necessary unless indicated by the facility's protocol or the client's condition; continuous IV tubing is typically changed every 72 to 96 hours unless there are signs of complications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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