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 D
Explanation
Rationale:
A. Ventrogluteal: The ventrogluteal site is preferred for intramuscular injections because it provides a large muscle mass with minimal risk of injury to nerves or blood vessels. It is not appropriate for subcutaneous injections, which require sites with adequate subcutaneous tissue rather than deep muscle.
B. Vastus lateralis: The vastus lateralis is commonly used for intramuscular injections, especially in infants and young children. For adults, it is not a typical site for subcutaneous injections due to the thicker muscle and risk of intramuscular delivery.
C. Forearm: The forearm is generally reserved for intradermal injections, such as tuberculin testing. Its limited subcutaneous tissue makes it unsuitable for subcutaneous injections intended to be absorbed slowly.
D. Upper thigh: The anterior or lateral aspect of the upper thigh provides an adequate layer of subcutaneous tissue, making it a safe and effective site for subcutaneous injections. It allows for slower absorption of medication and is easily accessible for the nurse.
Correct Answer is D
Explanation
Rationale:
A. Peripheral edema is present: Peripheral edema indicates fluid overload rather than restored fluid balance. Excess interstitial fluid reflects that the body has retained more fluid than necessary, which is a sign that fluid status is not yet normalized.
B. Crackles upon auscultation of the lungs: Lung crackles suggest pulmonary congestion, which is a sign of fluid overload. This finding indicates that fluid replacement may have exceeded the client’s needs, so fluid balance has not been restored appropriately.
C. Maternal heart rate is 110/min: Tachycardia can indicate ongoing hypovolemia or stress on the cardiovascular system. A normalized fluid balance would typically correspond with a heart rate within the client’s baseline range, generally around 60–100/min, rather than persistent tachycardia.
D. Urine output for 1 hour is 35 mL: Adequate urine output (generally ≥30 mL/hr for adults) indicates effective renal perfusion and suggests that intravascular volume has been restored. This is a key clinical indicator of fluid balance normalization following hemorrhage and fluid replacement.
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