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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Rationale:

A. Case manager: Case managers coordinate resources and support services for clients, including assistance with financial concerns and access to programs that provide free or low-cost baby formula. They are the best resource to help the client navigate community aid and social services.

B. Primary care provider: While the primary care provider manages the client’s overall health, they are not typically responsible for connecting clients with financial assistance programs related to infant feeding.

C. Nutritionist: Nutritionists provide dietary advice and education but generally do not address financial barriers or resource allocation for obtaining formula.

D. Pediatric nurse practitioner: Pediatric nurse practitioners focus on the infant’s health and development and may provide feeding guidance, but addressing the client’s financial inability to pay for formula falls outside their primary role.

A. "The client in room 205 has had several visitors today." B. "The client in room 204 received some pain medicine earlier today." C. "The client in room 205 is scheduled for a dressing change at 1800 D. "The client in room 203 will undergo surgery at 0900 tomorrow." E. "The client in room 204 has a new prescription for IV gentamicin”

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

Explanation

Rationale:

A. "The client in room 205 has had several visitors today." This is non-essential social information that does not contribute to continuity of care or clinical decision-making. Change-of-shift reports should focus on relevant clinical updates and care plans.

B. "The client in room 204 received some pain medicine earlier today." This statement lacks specificity, such as the type, dosage, time, and client response to the medication. Without detailed clinical context, the information is not useful for ensuring safe, consistent care.

C. "The client in room 205 is scheduled for a dressing change at 1800." This provides specific, actionable information that the oncoming nurse needs to know in order to follow the treatment plan and ensure timely wound care.

D. "The client in room 203 will undergo surgery at 0900 tomorrow." This is essential procedural information that allows the next nurse to prepare the client appropriately and monitor for any pre-op needs, such as NPO status or lab work.

E. "The client in room 204 has a new prescription for IV gentamicin." This communicates a significant change in the client’s medication regimen, which may require monitoring for side effects, such as nephrotoxicity or ototoxicity, making it critical to include in report.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is 2 days postpartum. The client tells the nurse she cannot afford to pay for baby formula. The nurse should refer the client to which of the following members of the interprofessional team?

Correct Answer is A

Explanation

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

Explanation

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