A nurse is receiving report about assigned clients at the start of his shift.
Which of the following clients should the nurse plan to attend to first?
A client who is scheduled for discharge in 2 hr following a laparoscopic tubal ligation.
A client who experienced a cesarean birth 4 hr ago and reports pain.
A client who has preeclampsia and a BP of 138/90 mm Hg.
A client who experienced a vaginal birth 24 hr ago and reports no bleeding.
The Correct Answer is B
Choice A rationale:
The nurse should prioritize the client's needs based on the severity of their condition. A client scheduled for discharge in 2 hours following a laparoscopic tubal ligation is generally stable and not in immediate need of care. Discharge planning can be done later.
Choice B rationale:
A client who experienced a cesarean birth 4 hours ago and reports pain requires immediate attention. Pain is a subjective symptom that should be addressed promptly to ensure the client's comfort and well-being. Uncontrolled pain can lead to complications and negatively affect the client's overall recovery.
Choice C rationale:
A client with preeclampsia and a blood pressure of 138/90 mm Hg is a concerning situation, but it is not the top priority in this scenario. Preeclampsia requires monitoring and intervention, but the client who just had a cesarean birth and is experiencing pain should be attended to first.
Choice D rationale:
A client who experienced a vaginal birth 24 hours ago and reports no bleeding is not a high-priority concern. Some clients may have minimal bleeding or none at all after a vaginal birth, and this can be normal. The absence of bleeding alone does not warrant immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
"This is a screening tool for spina bifida.”. This statement is incorrect. An ultrasound performed before an amniocentesis is not primarily used as a screening tool for spina bifida. Spina bifida can be detected through other diagnostic tests.
Choice B rationale:
"It is useful for estimating fetal age.”. While ultrasounds can provide information about fetal age, it is not the primary reason for performing an ultrasound before an amniocentesis. The main purpose is to identify the location of the placenta and fetus, which is essential for safely performing the amniocentesis procedure.
Choice C rationale:
"It assists in identifying the location of the placenta and fetus.”. This is the correct answer. An ultrasound before amniocentesis is crucial for locating the fetus and the placenta accurately. This information helps healthcare providers ensure the safe and precise insertion of the needle into the amniotic sac.
Choice D rationale:
"This will determine if there is more than one fetus.”. Determining if there is more than one fetus is an important aspect of prenatal care but is not the primary reason for performing an ultrasound before amniocentesis. It is generally confirmed through earlier ultrasounds during routine prenatal care. .
Correct Answer is B
Explanation
Choice A rationale:
Administering the measles, mumps, rubella (MMR) vaccine two weeks before attempting pregnancy again is not the correct timing. It is important to provide the MMR vaccine postpartum before the client is discharged from the hospital after giving birth. This timing is appropriate to protect the woman from rubella and to avoid vaccinating during pregnancy.
Choice B rationale:
The correct timing for the MMR vaccine is prior to discharge from the hospital after giving birth. This approach ensures that the woman is protected against rubella before leaving the hospital and potentially becoming pregnant again. It is crucial to avoid vaccinating during pregnancy because the MMR vaccine contains live attenuated viruses.
Choice C rationale:
Administering the MMR vaccine prior to giving birth is not the recommended timing. Vaccination should be done postpartum to avoid any potential risks to the developing fetus.
Choice D rationale:
Administering the MMR vaccine when the client does not desire future pregnancies is not the most appropriate option. The vaccine should be given postpartum to protect the woman and any future pregnancies from rubella. It is important to provide vaccination recommendations based on evidence-based guidelines and the client's specific situation.
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