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
Rationale:
A. "You will receive a dose of misoprostol to initiate contractions.": Misoprostol is used for cervical ripening and induction of labor, not for a contraction stress test. A CST uses nipple stimulation or low-dose oxytocin to produce mild contractions. Using misoprostol would create strong, prolonged contractions that could endanger the fetus.
B. "I will apply an external fetal heart rate monitor during the test.": A contraction stress test evaluates how the fetal heart rate responds to contractions. External fetal monitoring is required to record the fetal heart pattern and contraction frequency, allowing the provider to assess for late decelerations that indicate uteroplacental insufficiency. This reflects accurate and essential teaching for the procedure.
C. "I will give you a terbutaline injection after the test.": Terbutaline is a tocolytic used to stop contractions, but it is not routinely administered after a CST. The contractions produced during a CST are mild and temporary, and terbutaline is only given if excessive contractions occur, which is not expected in normal testing.
D. "I will apply an oxygen face mask during the test.": Oxygen is not routinely administered during a CST because the goal is to observe how the fetus tolerates normal physiologic contractions. Oxygen is used only if fetal distress occurs, so including it in routine teaching suggests an incorrect understanding of the procedure.
Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"B"}
Explanation
Rationale for Correct Choices
- Intravenous antibiotics: The client presents with uterine tenderness, dark foul-smelling lochia, a mildly elevated temperature, and an elevated WBC count, all of which point to endometritis, a common postpartum infection. The first-line treatment for endometritis is broad-spectrum IV antibiotics to prevent complications like sepsis.
- Increase in daily fluid intake: Infection and fever can increase fluid loss through insensible means, and fluids support circulation, renal function, and antibiotic delivery. Encouraging increased fluid intake also helps address dehydration from fever and supports healing and lactation.
Rationale for Incorrect Choices
- Kleihauer-Betke test: This test detects fetal-to-maternal hemorrhage and is used in trauma or suspected placental abruption in Rh-negative mothers. There is no indication of bleeding or Rh incompatibility in this case, so it is not appropriate here.
- Tocolytic medication: Tocolytics are used to suppress uterine contractions in preterm labor. This client is postpartum and has no signs of preterm labor or uterine hyperstimulation, so this medication is not warranted.
- Intrauterine tamponade balloon: This device is used for severe postpartum hemorrhage due to uterine atony that doesn’t respond to medical treatment. The client has moderate lochia but no signs of active hemorrhage or hemodynamic instability, so it is not indicated.
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