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 C

Explanation

Choice A rationale:

While there is a risk of infection with any internal examination, it is not the primary reason for avoiding internal examinations in a client with placenta previa. The main concern is avoiding trauma to the placenta, which could result in significant bleeding.

Choice B rationale:

Although internal examinations may potentially stimulate uterine contractions, leading to preterm labor in some cases, this is not the primary reason for avoiding such examinations in clients with placenta previa. The primary concern remains the risk of bleeding due to placental disruption.

Choice C rationale:

The correct explanation for the nurse to provide is that an internal examination could result in profound bleeding. Placenta previa occurs when the placenta partially or completely covers the cervix, and any manipulation of the cervix or uterus through an internal examination could disrupt the placenta and cause severe bleeding, endangering both the mother and the baby.

Choice D rationale:

While there is a risk of rupturing the membranes during an internal examination, this is not the primary reason for avoiding such examinations in clients with placenta previa. The primary concern remains the risk of bleeding due to placental disruption.

A. Instruct the client to wash their hands prior to breastfeeding. B. Teach the client about proper latching-on techniques. C. Encourage the client to alternate breastfeeding with formula feeding. D. Instruct the client to avoid using a breast pump. E. Encourage the client to allow their nipples to air dry after feedings.

Correct Answer is ["A","B","E"]

Explanation

Choice A rationale:

Instructing the client to wash their hands before breastfeeding helps prevent the transmission of infection to the breast and the baby.

Choice B rationale:

Teaching the client about proper latching-on techniques ensures effective breastfeeding, reduces the risk of nipple damage, and promotes comfort for both the client and the baby.

Choice C rationale:

Encouraging the client to alternate breastfeeding with formula feeding is not recommended for a client with mastitis. Mastitis is an inflammation of the breast tissue often caused by bacterial infection, and continuing breastfeeding helps to clear the infection and maintain milk supply.

Choice D rationale:

Instructing the client to avoid using a breast pump is not necessary in this situation. Breastfeeding and pumping can continue to help drain the breast adequately, which is essential for resolving mastitis.

Choice E rationale:

Encouraging the client to allow their nipples to air dry after feedings helps promote healing and prevents further irritation to the nipples.

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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 nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?

Correct Answer is C

Explanation

A nurse is planning care for a client who is 2 weeks postpartum and has mastitis. Which of the following interventions should the nurse include? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

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