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 A
Explanation
Choice A rationale:
Checking the fetal heart rate pattern is the priority nursing action following an amniotomy. This procedure involves rupturing the amniotic membranes, which can result in changes to the baby's heart rate. It's essential to assess the fetal heart rate to ensure the baby is tolerating the procedure well and to identify any signs of fetal distress promptly.
Choice B rationale:
Evaluating the client for signs of infection is an important step after an amniotomy, but it is not the top priority. The immediate concern is the well-being of the fetus, and assessing the fetal heart rate takes precedence.
Choice C rationale:
Taking the client's temperature is relevant to monitor for infection, but it should not be the first action. Monitoring the fetus's status with a fetal heart rate assessment is more critical in this situation.
Choice D rationale:
Observing the color and consistency of amniotic fluid is a valuable assessment but not the top priority. It can provide information about meconium staining or other issues, but assessing the fetal heart rate is more crucial immediately after the procedure.
Correct Answer is B
Explanation
Choice A rationale:
Quickening occurs between the first and second months of pregnancy. This statement is incorrect. Quickening is the term used to describe the first sensations of fetal movement, which usually occur between the 18th and 20th weeks of pregnancy. During the first and second months of pregnancy, the fetus is too small for the mother to feel any movement. This choice is inaccurate.
Choice B rationale:
Quickening occurs between the fourth and fifth months of pregnancy. This is the correct choice. Quickening typically occurs between the 18th and 20th weeks of pregnancy. It marks an important milestone in pregnancy when the mother can start feeling the baby's movements. This is a key point to include in teaching.
Choice C rationale:
Quickening starts soon after implantation. This statement is inaccurate. Quickening does not occur immediately after implantation. Implantation typically occurs around 6-10 days after fertilization. Quickening happens much later in pregnancy, as previously mentioned, between the fourth and fifth months.
Choice D rationale:
Quickening starts during the last weeks of pregnancy. This statement is also incorrect. Quickening is a term used to describe the first movements of the fetus, and it occurs during the second trimester of pregnancy, not during the last weeks. This choice is not accurate.
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