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:
• Temperature: An elevated temperature of 39.3° C is consistent with an active infection like pneumonia. This finding supports the need for antibiotic treatment and does not delay administration unless linked to an adverse drug reaction.
• WBC count: A WBC count of 16,000/mm³ indicates leukocytosis, which is expected in bacterial pneumonia. It confirms infection and the need for antibiotics, not a reason to withhold cefazolin.
• Allergies: The client has a documented allergy to penicillin, which is critical because cefazolin is a cephalosporin. Cephalosporins share a similar beta-lactam structure and can cross-react in clients with penicillin allergies, increasing the risk of anaphylaxis. Reporting this ensures safe prescribing and prevents a life-threatening hypersensitivity reaction.
• Chest x-ray: The left lower lobe density confirms pneumonia. This imaging supports the clinical decision to administer antibiotics and does not warrant withholding the prescribed medication.
Correct Answer is B
Explanation
Rationale:
A. Encourage the client to increase fluid intake: Clients receiving continuous peritoneal dialysis may need to restrict fluids to prevent volume overload, depending on residual kidney function and dialysis efficiency. Encouraging increased intake without provider orders can be harmful.
B. Obtain the client's weight: Daily weight is a critical indicator of fluid balance and dialysis effectiveness. Monitoring weight helps determine if the dialysis is removing the appropriate amount of fluid and supports adjustments to the treatment plan.
C. Palpate the access site for a thrill: A thrill is a vibration felt over an arteriovenous fistula, which is used in hemodialysis, not peritoneal dialysis. Peritoneal dialysis uses a soft catheter in the abdomen and does not produce a thrill.
D. Auscultate the access site for a bruit: A bruit, a whooshing sound heard over a vascular access, is associated with AV fistulas used in hemodialysis. It is not relevant for peritoneal dialysis, which uses a catheter and does not involve high-pressure blood flow.
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