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 B
Explanation
Rationale:
A. 1/2 cup of corn: While corn contains some folate, the amount is relatively low compared to legumes and leafy greens. It is not considered one of the best sources of folic acid for meeting the increased demands of early pregnancy.
B. 1/2 cup of cooked lentils: Lentils are among the richest natural sources of folic acid, providing a significant portion of the recommended daily intake. They are especially beneficial during early pregnancy to help prevent neural tube defects in the developing fetus.
C. 1 fried egg: Eggs provide a small amount of folate but are not a primary source. Although eggs offer other important nutrients during pregnancy, they do not meet the body’s high folic acid needs at 8 weeks gestation.
D. 1 slice of toast: Most bread products in some regions are fortified with folic acid, but the quantity in a single slice is minimal. While it can contribute to daily intake, it is not as concentrated a source as legumes like lentils.
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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