A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to attend to first?
A client who reports changing their perineal pad every 4 hr.
A client who has a urine output of 750 mL in 6 hr.
A client who has 1+ deep tendon reflexes while receiving IV magnesium sulfate.
A client who reports abdominal cramping pain during breastfeeding.
The Correct Answer is A
A. Changing a perineal pad only every 4 hours may indicate excessive bleeding or hemorrhage, which requires immediate assessment.
B. A urine output of 750 mL in 6 hours is within normal limits (about 125 mL/hr).
C. 1+ deep tendon reflexes indicate decreased reflexes, which is expected during magnesium sulfate therapy and generally not an immediate concern.
D. Abdominal cramping during breastfeeding is common due to uterine contractions and is usually not urgent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. An indwelling urinary catheter is typically inserted before surgery, not immediately after, to keep the bladder empty during the procedure.
B. Applying sequential compression devices prior to the procedure is a key intervention to prevent deep vein thrombosis, which is a high-risk complication for clients undergoing cesarean birth.
C. Performing a surgical timeout is important but is a standard surgical protocol rather than a nursing-specific intervention for cesarean birth preparation.
D. Oxytocin is administered after delivery of the placenta to promote uterine contraction and prevent postpartum hemorrhage, not before surgery.
Correct Answer is D
Explanation
A. Breastfeeding is not contraindicated in mothers with hepatitis B if the newborn receives appropriate prophylaxis.
B. Airborne precautions are not necessary; hepatitis B is transmitted through blood and body fluids, not airborne droplets.
C. Bathing the newborn does not affect hepatitis B transmission risk and does not need to be delayed.
D. Administering hepatitis B immune globulin (HBIG) IM to the newborn within 12 hours of birth, along with the first dose of the hepatitis B vaccine, is essential to prevent vertical transmission of hepatitis B virus.
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