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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Gender of the fetus. Amniocentesis is a medical procedure used to sample amniotic fluid surrounding the fetus in the womb. It is primarily performed to obtain information about the fetus's health and development. Determining the gender of the fetus is not a standard indication for amniocentesis.
Choice B rationale:
Weeks of gestation. This is the correct answer. Amniocentesis is often performed to determine the gestational age of the fetus. It helps healthcare providers confirm the number of weeks of gestation and ensure the fetus is at an appropriate developmental stage.
Choice C rationale:
Anatomic abnormalities. Amniocentesis can be used to detect certain chromosomal abnormalities and genetic disorders in the fetus, but it is not primarily performed to identify anatomic abnormalities.
Choice D rationale:
Maturity of lungs. Determining the maturity of the fetus's lungs is typically done using other methods, such as assessing lung function and surfactant levels. It is not the primary purpose of amniocentesis.
Correct Answer is B
Explanation
To calculate the estimated date of delivery (EDD) using Naegele’s rule, the nurse would:
- Add one year to the year of the last menstrual period (LMP).
- Subtract three months from the month of the LMP.
- Add seven days to the day of the LMP.
Given the first day of the client’s last menstrual period was April 4, 2023:
- Adding one year: April 4, 2024
- Subtracting three months: January 4, 2024
- Adding seven days: January 11, 2024
So, the nurse should tell the client that her estimated date of delivery (EDD) isJanuary 11, 2024.
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