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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Raloxifene is not used to treat migraines. It is a selective estrogen receptor modulator (SERM) that primarily acts on bone tissues, estrogen receptors, and has anti-estrogenic effects in the breast, which may reduce the risk of breast cancer.
Choice B rationale:
Raloxifene is not used to treat hypertension (high blood pressure) It is primarily indicated for the prevention and treatment of osteoporosis in postmenopausal women.
Choice C rationale:
This is the correct choice. Raloxifene is indicated for the treatment and prevention of osteoporosis in postmenopausal women. It helps increase bone density and reduces the risk of fractures associated with osteoporosis.
Choice D rationale:
Raloxifene is not used to treat heart disease. While it may have some cardiovascular benefits due to its effects on cholesterol levels, it is not a primary medication for heart disease management.
Correct Answer is C
Explanation
Choice A rationale:
Keeping the newborn dressed while receiving phototherapy is not recommended because the baby's skin needs to be exposed to the light to effectively treat hyperbilirubinemia. Direct exposure to light helps break down the excess bilirubin in the baby's blood, leading to its excretion.
Choice B rationale:
Applying lotion to the skin twice daily is contraindicated during phototherapy. Lotions and creams can block the light from reaching the skin and hinder the therapeutic effects of the phototherapy. The baby's skin should remain exposed to the light for optimal treatment.
Choice C rationale:
Maintaining an eye mask over the newborn's eyes is essential during phototherapy. The eyes are sensitive to light, and prolonged exposure to the phototherapy light can lead to eye damage. Using an eye mask protects the baby's eyes while allowing the rest of the body to receive the necessary light treatment.
Choice D rationale:
Maintaining the phototherapy during blood draws is crucial to ensure continuous treatment of hyperbilirubinemia. Interrupting the phototherapy during blood draws might result in the rebound of bilirubin levels, which can be harmful to the baby.
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