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 D
Explanation
Choice A rationale:
The instruction to "cover the cord with the diaper" is incorrect. It's essential to keep the umbilical cord stump dry and exposed to air to promote healing. Covering it with a diaper can trap moisture and increase the risk of infection.
Choice B rationale:
The recommendation to "wrap the cord in petroleum jelly gauze" is not appropriate. Applying petroleum jelly or other ointments to the cord stump is not recommended, as it can also trap moisture and create an environment for bacterial growth.
Choice C rationale:
The instruction to "bathe the newborn with a washcloth until the cord stump falls off" is not the best practice. It's advisable to give sponge baths and avoid submerging the cord stump until it has completely dried and fallen off. Using a washcloth may cause unnecessary friction and irritation.
Choice D rationale:
The advice to "wash the cord daily with mild soap and water" is the correct instruction. Cleaning the cord stump with mild soap and water and then gently patting it dry with a clean cloth is a standard practice for cord care. Keeping the area clean helps prevent infection and promotes healing.
Correct Answer is ["C","E"]
Explanation
A nurse is preparing to examine a post-term newborn immediately following delivery. Which of the following findings should she expect to observe? (Select all that apply.) The correct answers are choices C and E: Cracked, peeling skin and Vernix in the folds and creases.
Choice A rationale:
The Moro reflex is a normal neonatal reflex that can be observed in newborns at term or preterm, not specifically in post-term newborns. It is characterized by the baby's response to a sudden loss of support, which causes them to startle, throw their arms out, and cry. This reflex is not unique to post-term newborns.
Choice B rationale:
The heel to ear maneuverability is not a typical finding in newborn assessments. It is not related to the term or post-term status of the newborn. Therefore, this choice is not applicable.
Choice C rationale:
Cracked, peeling skin is a common finding in post-term newborns. Post-term babies have been in the womb for a longer duration, which can lead to changes in the condition of their skin, including peeling and cracking. This is due to prolonged exposure to amniotic fluid and the protective vernix diminishing.
Choice D rationale:
Abundant lanugo is more commonly found in preterm or premature newborns. As babies approach their due date and beyond, they tend to shed this fine, downy hair. Therefore, this choice is not applicable to post-term newborns.
Choice E rationale:
Vernix in the folds and creases is a characteristic finding in post-term newborns. Vernix is a white, waxy substance that coats the skin of newborns. In post-term babies, this vernix may be found in the folds and creases of their skin, as they have had more time in the womb for it to accumulate.
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