A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

A client who gave birth 1 day ago and needs Rh(D) immune globulin.

A client who gave birth 3 days ago and reports breast fullness.

A client who gave birth 12 hr ago and reports an increase in urinary output.

A client who gave birth 8 hr ago and is saturating a perineal pad every hour.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

A client who gave birth 1 day ago and needs Rh(D) immune globulin should be seen soon but not necessarily first. Rh(D) immune globulin is administered to Rh-negative mothers with Rh- positive infants to prevent isoimmunization in future pregnancies.

Choice B rationale:

A client who gave birth 3 days ago and reports breast fullness is likely experiencing normal postpartum breast engorgement. This client can be attended to after the client with more urgent symptoms.

Choice C rationale:

A client who gave birth 12 hours ago and reports an increase in urinary output might have diuresis, which is a common postpartum physiological change. Although this requires assessment, it is not as urgent as the client in choice D.

Choice D rationale:

The nurse should see the client who gave birth 8 hours ago and is saturating a perineal pad every hour first because excessive postpartum bleeding could indicate hemorrhage, a potentially life-threatening complication. Immediate assessment and intervention are crucial in this situation.

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Correct Answer is A

Explanation

Choice A rationale:

Naegele's Rule is used to estimate the expected delivery date (EDD) by adding 7 days and 9 months to the first day of the last menstrual period (LMP) In this case, May 4th, 2018, is the first day of the LMP. Adding 7 days brings us to May 11th, and then adding 9 months brings us to February 11th, 2019, which is the estimated delivery date.

Choice B rationale:

This option is incorrect because it adds 9 months to the LMP without accounting for the additional 7 days, resulting in an inaccurate EDD.

Choice C rationale:

This option is incorrect because it only adds 9 months to the LMP without considering the 7 days, leading to an inaccurate EDD.

Choice D rationale:

This option is incorrect because it adds 9 months to the LMP without considering the 7 days, resulting in an inaccurate EDD.

A. Peanut butter sandwich on wheat bread. B. A sliced apple and red grapes. C. A chocolate chip cookie with a glass of skim milk. D. A scrambled egg with cheddar cheese.

Correct Answer is B

Explanation

A. Peanut butter and wheat bread contain high levels of phenylalanine, which should be avoided in clients with phenylketonuria.
B. A sliced apple and red grapes are low in phenylalanine and are safe choices for a client with phenylketonuria.
C. Chocolate, cookies, and milk contain phenylalanine, making them unsuitable for the client.
D. Eggs and cheese are high in phenylalanine and should be restricted in the diet.

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A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A pregnant client's last menstrual period was May 4th, 2018. What is this client's estimated delivery date using Naegele's Rule?

Correct Answer is A

Explanation

A nurse providing dietary teaching for a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following suggested foods should the nurse include in the teaching?

Correct Answer is B

Explanation

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