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. Point out to the father that the newborn turns toward his voice. B. Ask the father why he is concerned about bonding with the newborn. C. Encourage the father to touch and stroke the newborn's skin. D. Demonstrate diapering and swaddling techniques for the father. E. Encourage the father to lay the newborn beside him while both are sleeping.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale:

Pointing out to the father that the newborn turns toward his voice helps him understand that the baby is already responding to him, promoting bonding.

Choice B rationale:

Asking the father why he is concerned about bonding with the newborn allows the nurse to address specific fears or misconceptions and provide appropriate support.

Choice C rationale:

Encouraging the father to touch and stroke the newborn's skin promotes physical contact and enhances the bonding process.

Choice D rationale:

Demonstrating diapering and swaddling techniques for the father helps him feel more confident in caring for his baby and fosters bonding through caregiving activities.

Choice E rationale:

Encouraging the father to lay the newborn beside him while both are sleeping promotes skin- to-skin contact and allows for bonding during restful moments. However, the nurse should ensure that safety measures are followed to prevent accidental suffocation. By following these actions, the nurse can support the father's bonding with his newborn and facilitate a positive and nurturing parent-infant relationship.

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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 is caring for a newborn whose father voices concerns about his ability to bond with his baby. Which of the following actions should the nurse take to facilitate bonding? (Select all that apply.)

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?

A nurse is assessing a newborn who is 48 hr old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?

A nurse is conducting an infertility assessment for a newly admitted client. Which of the following factors should the nurse identify as affecting the client's fertility?

A nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis gravidarum. Which of the following medications should the nurse plan to administer?

A nurse is caring for a client who is experiencing urinary incontinence. Which of the following recommendations should the nurse include in the teaching plan for this client?

A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. Which of the following results should the nurse report to the provider?

A nurse is caring for a laboring client and notes that the fetal heart rate begins to decelerate after the contraction has started. The lowest point of deceleration occurs after the peak of the contraction. What is the priority nursing action?

A nurse is caring for a client who is at 38 weeks of gestation and is experiencing continuous abdominal pain and vaginal bleeding. The client has a history of cocaine use. The nurse should identify that the client is likely experiencing which of the following complications?