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 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.

A. Assist with deep breathing and coughing. B. Monitor the incision site for findings of infection. C. Assess fluid intake every 24 hr. D. Ambulate three times a day.

Correct Answer is A

Explanation

A. Assisting with deep breathing and coughing is the priority action. This is crucial in preventing respiratory complications, such as atelectasis or pneumonia, especially following abdominal surgery. Deep breathing exercises can help expand the lungs and promote ventilation.

B. Monitoring the incision site for signs of infection is important, but it is not the immediate priority. The client’s respiratory function takes precedence in the early postoperative period.

C. Assessing fluid intake is important for overall recovery, but it is not as critical as ensuring the client can breathe effectively and prevent complications.

D. While ambulation is beneficial for recovery and preventing complications such as deep vein thrombosis, the nurse must first ensure the client can manage their airway and breathing.

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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

A nurse is teaching a client who has a new prescription for digoxin about manifestations of toxicity. Which of the following findings should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority?

Correct Answer is A

Explanation

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