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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Bending at the waist to put on slippers places the hip in flexion greater than 90 degrees, which increases the risk of dislocation after total hip arthroplasty.
B. Keeping the client’s heels elevated while in bed helps prevent pressure injuries and promotes skin integrity. This is a safe and appropriate action for a client post-hip arthroplasty.
C. Massaging the affected leg is contraindicated because it can dislodge a blood clot and increase the risk of deep vein thrombosis.
D. Maintain slight abduction of the client’s affected hip: Keeping the hip in slight abduction with pillows or abduction devices helps prevent dislocation of the prosthetic joint. Proper positioning is essential for safe recovery following total hip arthroplasty.
Correct Answer is C
Explanation
Rationale:
A. Provide the child with electronics to watch movies: While distraction can be helpful in managing anxiety or discomfort, it does not directly address the child’s feelings about hair loss. Emotional support specific to the child’s concern is more appropriate in this situation.
B. Tell the child there's no need to cry because this is expected: Minimizing the child’s feelings invalidates their emotional experience and can increase distress. Acknowledging and supporting the child’s emotions is essential for coping during hair loss caused by radiation therapy.
C. Provide the child with a doll that does not have any hair: Giving a doll without hair helps the child normalize hair loss and provides a concrete way to express and cope with feelings. This action demonstrates understanding, empathy, and age-appropriate support for the child’s emotional needs.
D. Tell the child not to worry about their hair loss because their hair will grow back: While it is true that hair often regrows after treatment, reassurance alone does not address the child’s immediate emotional reaction. Supporting the child’s feelings and providing relatable coping strategies is more effective.
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