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 C
Explanation
Rationale:
A. Remove the client's dentures from their mouth before rigor mortis begins: Removing dentures is generally done after rigor mortis to maintain the natural appearance of the face for viewing. Premature removal can alter facial structure and affect family perceptions.
B. Turn on all the lights in the room before the family views the client's body: Bright lighting may be uncomfortable or overwhelming for grieving family members. Soft, gentle lighting is usually preferred to create a calm and respectful environment.
C. Ask the client's family about cultural or religious practices regarding postmortem care: Different cultures and religions have specific rituals and practices for caring for the deceased. Inquiring about these preferences ensures that the nurse respects the family’s beliefs and supports culturally sensitive care.
D. Position the client's bed flat without a pillow under their head: After death, the head of the bed should be slightly elevated (e.g., 15-30 degrees) to prevent blood from pooling in the face and causing discoloration, which can be distressing for the family.
Correct Answer is D,C,B,A
Explanation
Rationale:
D. Inspection: This is always the first step in any physical assessment. The nurse observes the abdomen for contour, symmetry, skin condition, and any visible movements or abnormalities.
C. Auscultation: Performed before palpation to avoid altering bowel sounds. Listening to bowel and vascular sounds provides key information about gastrointestinal activity and blood flow.
B. Light palpation: Conducted next to assess for tenderness, guarding, and superficial masses. This helps ensure client comfort and provides a baseline before deeper pressure is applied.
A. Deep palpation: Done last to evaluate organ size, deep masses, or tenderness. It can stimulate peristalsis or discomfort, so it follows the less invasive steps to minimize changes to assessment findings.
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