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

The correct answer is A. Initiate continuous monitoring of the FHR. For a client with placenta previa, continuous fetal heart rate (FHR) monitoring is essential to assess the baby's well-being due to the risk of fetal distress from reduced oxygen supply

Choice A reason:

Continuous FHR monitoring is a standard care practice for clients with placenta previa to promptly detect any signs of fetal distress and intervene as necessary.

Choice B reason:

Betamethasone is typically administered to enhance fetal lung maturity before 34 weeks of gestation, not for placenta previa. Its use at 35 weeks is less common unless there's a risk of preterm birth within 7 days and the patient hasn't received a previous course.

Choice C reason:

Checking the cervix can induce bleeding and is contraindicated in placenta previa because it may disturb the placental site and exacerbate bleeding.

Choice D reason:

Misoprostol is used for labor induction or to treat postpartum hemorrhage. It is not indicated for placenta previa management and can cause uterine contractions leading to increased bleeding.

A. Heart disease. B. Cervical dilation of 2 cm. C. Gestational age of 34 weeks. D. Allergy to penicillin.

Correct Answer is A

Explanation

Choice A rationale:

Terbutaline is a medication commonly used to stop preterm labor by relaxing the uterine muscles. However, it is contraindicated in clients with heart disease or certain cardiac conditions, as it can cause cardiovascular side effects such as increased heart rate, palpitations, and potential arrhythmias.

Choice B rationale:

Cervical dilation of 2 cm is a typical sign of preterm labor, and the prescription for terbutaline is appropriate to prevent further cervical dilation and delay delivery.

Choice C rationale:

A gestational age of 34 weeks indicates preterm labor, which is precisely the scenario where terbutaline would be administered to halt labor progression and extend the pregnancy.

Choice D rationale:

Allergy to penicillin is unrelated to the administration of terbutaline, as they are different medications with distinct mechanisms of action and side effects.

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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 admitting a client who is at 35 weeks of gestation and is experiencing mild vaginal bleeding due to placenta previa. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is caring for a client who is experiencing preterm labor and has a new prescription for terbutaline. Which of the following findings is a contraindication for the administration of this medication?

Correct Answer is A

Explanation

A nurse is caring for a client who is in active labor. The nurse notes early decelerations of the FHR on the fetal monitor tracing. The nurse should identify that which of the following conditions causes early decelerations in the FHR?

A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?

A nurse is reviewing the laboratory results of a newborn who is 24 hr old. Which of the following findings should the nurse report to the provider?

A nurse is assessing a client who is at 31 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential prenatal complication?

Prior to an amniocentesis, what action by the client will need to be completed?

A nurse is planning care for a newborn who is small for gestational age (SGA) Which of the following is the priority intervention the nurse should include in the newborn's plan of care?

A nurse is assessing a client who gave birth 12 hr ago and is experiencing excessive vaginal bleeding. Which of the following findings indicates the client is experiencing decreased cardiac output?

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?