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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Catheterization may be necessary if the client cannot void but is not the first step before ambulation.
B. Evaluating deep tendon reflexes is more relevant for clients receiving magnesium sulfate, not primarily for epidural assessment.
C. Assessing motor function of the lower extremities ensures the client has adequate strength and sensation to safely ambulate after an epidural.
D. Administering meperidine is for pain management and does not relate to safety before ambulation.

A. Consistent crying B. Hand-to-mouth movements C. Rooting reflex D. Sucking motions E. The Babinski reflex

Correct Answer is ["B","C","D"]

Explanation

B. Hand-to-mouth movements are an early hunger cue as the newborn tries to self-soothe or indicate readiness to feed.

C. Rooting reflex is a classic early sign where the newborn turns their head toward the stimulus (like a nipple) indicating hunger.

D. Sucking motions suggest the newborn is preparing or ready to feed.

A. Consistent crying is a late hunger cue and can indicate distress if earlier cues are missed.

E. The Babinski reflex is a neurological reflex unrelated to hunger cues.

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A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to attend to first?

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