A nurse is providing care for a group of postpartum clients. Which of the following clients should the nurse see first?

A client who is 4 hr postpartum and has a heart rate of 90/min

A client who is 4 days postpartum and has a WBC count of 18,000/mm3 (5,000 to 10,000/mm3)

A client who is 12 hr postpartum and has an oral temperature of 37.8° C (100° F)

A client who is 2 days postpartum and reports dysuria

Answer and Explanation

The Correct Answer is B

Rationale:

A. A client who is 4 hr postpartum and has a heart rate of 90/min: A heart rate of 90/min is within normal postpartum limits. This client is stable and does not require immediate assessment, making them a lower priority compared to clients showing signs of possible infection or complications.

B. A client who is 4 days postpartum and has a WBC count of 18,000/mm³ (5,000 to 10,000/mm³): An elevated WBC count 4 days postpartum can indicate a serious infection, such as endometritis or another postpartum infection. This client is at risk for rapid deterioration and requires immediate assessment and intervention.

C. A client who is 12 hr postpartum and has an oral temperature of 37.8° C (100° F): A mild temperature elevation shortly after birth can be expected due to normal postpartum physiologic changes. While it should be monitored, it is not as urgent as the markedly elevated WBC count indicating potential infection.

D. A client who is 2 days postpartum and reports dysuria: Dysuria may indicate a urinary tract infection, which requires evaluation, but this is less immediately threatening than a client with signs of systemic infection. This client should be assessed after clients with potential severe infection or hemodynamic instability.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Rationale for correct choices

• Compartment syndrome: The child has a nondisplaced fracture of the radius and ulna, which can lead to swelling and increased pressure within the forearm compartments. Compartment syndrome is a serious complication that can compromise circulation and nerve function if not identified and treated promptly. Early recognition is critical to prevent permanent muscle and nerve damage.

• Paresthesia: The child reports mild tingling in the fingers, indicating early sensory nerve involvement. Paresthesia is a key early sign of neurovascular compromise in compartment syndrome. Monitoring for worsening tingling, numbness, or pain is essential for timely intervention, such as fasciotomy if needed.

Rationale for incorrect choices

• Deep vein thrombosis: DVT is uncommon in pediatric patients, especially in the absence of immobility, central lines, or hypercoagulable conditions. While fractures increase risk in adults, it is not the highest-priority risk in this 9-year-old child with an acute upper extremity fracture.

• Malunion: Malunion refers to healing of a fracture in an abnormal position. While possible, this risk develops over time and is not the immediate concern in the acute phase. Neurovascular compromise and compartment syndrome are more urgent.

• Type of fracture: While the fracture type (nondisplaced radius and ulna) informs management, it does not by itself represent the complication risk. The clinical symptoms of tingling are more directly indicative of acute neurovascular compromise.

• Ecchymosis: Bruising reflects local tissue trauma but is not a definitive indicator of compartment syndrome. Ecchymosis should be monitored but does not provide the highest-priority evidence of risk.

• Location of fracture: The midshaft location guides treatment, such as splinting, but the presence of paresthesia is more directly associated with risk for compartment syndrome. Location alone does not indicate imminent neurovascular compromise.

A. A client who has a complete femur fracture and reports a pain level of 7 on a scale from 0 to 10 B. A client who has left shoulder pain and S-T elevation on a 12-lead ECG C. A client who has Clostridium difficile and a temperature of 38.5° C(101.5°F) D. A client who has orthostatic hypotension and 4 pitting edema in the lower extremities

Correct Answer is B

Explanation

Rationale:

A. A client who has a complete femur fracture and reports a pain level of 7 on a scale from 0 to 10: Severe pain is significant and requires timely management, but it is not immediately life-threatening compared to acute cardiac events. Pain control should follow stabilization of critical conditions.

B. A client who has left shoulder pain and S-T elevation on a 12-lead ECG: ST-segment elevation indicates a possible acute myocardial infarction, which is a life-threatening emergency. Prompt assessment and intervention are crucial to prevent cardiac damage or death, making this the highest priority.

C. A client who has Clostridium difficile and a temperature of 38.5°C (101.5°F): Fever and infection require attention, but this client is currently stable compared with someone experiencing an acute myocardial infarction. Infection control and monitoring can follow stabilization of higher-priority emergencies.

D. A client who has orthostatic hypotension and 4+ pitting edema in the lower extremities: These findings indicate fluid imbalance and cardiovascular compromise, but they are not as immediately life-threatening as an acute STEMI. Monitoring and management should follow urgent cardiac care.

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A nurse is providing care for a group of postpartum clients. Which of the following clients should the nurse see first?

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Explanation

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