A nurse is caring for a group of clients who are postpartum.
Which of the following clients is at an increased risk for a fall?
A client who has an indwelling urinary catheter.
A client who has a second-degree perineal laceration.
A client who is saturating a perineal pad every 5 to 6 hr.
A client who is experiencing breast engorgement.
The Correct Answer is A
Choice A rationale
An indwelling urinary catheter can increase the risk of falls because it may cause discomfort and restricted mobility, leading the client to move awkwardly or lose balance.
Choice B rationale
While a second-degree perineal laceration might cause pain and limited mobility, it doesn't usually contribute as significantly to fall risk as an indwelling catheter.
Choice C rationale
Saturating a perineal pad every 5 to 6 hours may indicate heavy postpartum bleeding, but it isn't directly related to fall risk. The concern here would be more about monitoring for hemorrhage rather than falls.
Choice D rationale
Breast engorgement causes discomfort and pain but doesn't directly affect a client's mobility or balance, making it less likely to increase fall risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E","F"]
Explanation
B. "You may experience a headache after receiving this medication."
- Some tocolytic medications can cause headaches as a side effect.
C. "It is common for this medication to make you feel jittery."
- Tocolytic medications, such as terbutaline, can cause nervousness or jitteriness.
D. "This medication should decrease your contractions."
- The primary purpose of tocolytic medication is to decrease uterine contractions and delay preterm labor.
E. "I'll check your reflexes frequently while you are receiving this medication."
- Some tocolytic medications, like magnesium sulfate, require monitoring of deep tendon reflexes to assess for potential toxicity.
F. "This medication can make your heart beat faster."
- Tocolytic medications, such as terbutaline, can increase heart rate.
These statements provide the client with a comprehensive understanding of the purpose of the medication and its potential side effects.
The incorrect statements are:
- A. "I will inject this medication under your skin.": Tocolytic medications are typically administered orally, intravenously, or intramuscularly, not subcutaneously.
- G. "This medication can increase your blood pressure.": Some tocolytic medications, like magnesium sulfate, can actually lower blood pressure rather than increase it.
Correct Answer is D
Explanation
Choice A rationale
Transient circumoral cyanosis is common in newborns, especially when crying or feeding, and usually resolves on its own without intervention.
Choice B rationale
Transient strabismus, or the temporary crossing of the eyes, is normal in newborns due to underdeveloped eye muscles and usually resolves as the infant grows.
Choice C rationale
Caput succedaneum is the swelling of the scalp caused by pressure during delivery. It is usually benign and resolves within a few days without treatment.
Choice D rationale
Generalized petechiae, or small red or purple spots on the skin, can indicate a serious underlying condition such as a clotting disorder or infection and requires immediate medical evaluation.
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