A nurse on a postpartum unit is receiving change-of-shift report for 4 clients. Which of the following clients should the nurse plan to see first?
A client who gave birth 6 hr ago and just received a dose of methylergonovine
A client who gave birth 24 hr ago and has had a urinary output of 2800 mL
A client who is 3 days postpartum and reports bilateral breast fullness
A client who gave birth 8 hr ago and has moderate perineal edema
The Correct Answer is A
Rationale:
A. A client who gave birth 6 hr ago and just received a dose of methylergonovine: Methylergonovine is used to control postpartum hemorrhage but can cause severe hypertension or other adverse effects. Close monitoring immediately after administration is critical to detect complications early.
B. A client who gave birth 24 hr ago and has had a urinary output of 2800 mL: Increased urinary output postpartum is common due to diuresis as the body eliminates excess fluid; this is not an urgent concern if the client is otherwise stable.
C. A client who is 3 days postpartum and reports bilateral breast fullness: Breast engorgement is common around this time and is expected. It can be managed with supportive measures and is not an immediate priority.
D. A client who gave birth 8 hr ago and has moderate perineal edema: Perineal edema is expected postpartum and usually resolves with routine care. Unless associated with severe pain or signs of infection, it does not require immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "Go to bed at least 2 hours earlier than usual.": Going to bed earlier may increase total sleep time, but it does not directly address the cause of nighttime awakening—frequent urination. Earlier bedtime alone is unlikely to improve the client’s quality of sleep.
B. "Have a snack before bedtime.": A bedtime snack may help prevent nausea or maintain blood sugar levels but does not reduce nighttime urinary frequency. In some cases, it might lead to increased fluid intake, potentially worsening nocturia.
C. "Drink a cup of chamomile tea at bedtime.": While chamomile may promote relaxation, it is also a fluid, which can increase bladder activity during the night. Encouraging tea before bed may worsen the client's urinary frequency and sleep disruption.
D. "Take regular rest periods during the day.": Taking rest periods throughout the day can help reduce overall fatigue and minimize sleep disruption caused by nocturia. Resting during the day compensates for nighttime interruptions and supports maternal well-being in early pregnancy.
Correct Answer is B
Explanation
Rationale:
A. "Why have you changed your mind about the procedure?": Asking “why” can feel confrontational and may pressure the client to justify their decision rather than respecting their autonomy. It’s better to acknowledge their feelings without judgment.
B. "You have the right to refuse the procedure.": Affirming the client’s right to refuse respects their autonomy and legal rights. It opens the door for further discussion and ensures informed consent is voluntary and ongoing.
C. "Have you had any troubles with swallowing?": This question is unrelated to the client’s decision to refuse the bronchoscopy and does not address their expressed concern or right to refuse.
D. "Your doctor wants you to have this procedure.": Emphasizing the provider’s wishes may pressure the client and undermine their autonomy. The nurse’s role is to support informed decision-making, not to coerce.
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