A nurse on the postpartum unit is assisting with the care of a group of clients.
Which of the following clients should the nurse plan to see first?
A client who gave birth 18 hours ago and has a temperature of 37.8°C (100°F).
A G2P1 client who gave birth 8 hours ago and reports abdominal pain during breastfeeding.
A client who gave birth 24 hours ago and reports not yet having a bowel movement.
A G5P4 client who gave birth 6 hours ago and has saturated one perineal pad over the past 2 hours.
The Correct Answer is D
Choice A rationale
A temperature of 37.8°C (100°F) 18 hours postpartum is slightly elevated but not necessarily indicative of a serious issue. It may require monitoring but is not the most urgent concern.
Choice B rationale
Abdominal pain during breastfeeding 8 hours postpartum is a common experience due to uterine contractions. While it may cause discomfort, it is not typically an urgent concern.
Choice C rationale
Not having a bowel movement 24 hours postpartum is not uncommon and does not usually require immediate attention. It can be addressed with dietary changes and other interventions.
Choice D rationale
Saturating one perineal pad over 2 hours 6 hours postpartum in a G5P4 client indicates a potential risk of postpartum hemorrhage. This is a more urgent concern that requires immediate assessment and intervention to prevent complications. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
There is no need to fast before a nonstress test. The test measures the fetal heart rate in response to fetal movements and does not require any dietary restrictions.
Choice B rationale
During a nonstress test, the client will press a button whenever they feel the baby move. This helps correlate fetal movements with heart rate changes.
Choice C rationale
The client is not required to lie flat on their back for the duration of the test. They can be in a semi-reclined position to ensure comfort and avoid supine hypotensive syndrome.
Choice D rationale
Medication to stimulate contractions is not used during a nonstress test. This is done during a contraction stress test, which is a different procedure.
Correct Answer is C
Explanation
Choice A rationale
Applying lotion to the newborn’s extremities every 8 hours is not recommended during phototherapy. Lotions and ointments can cause burns when exposed to phototherapy lights and may interfere with the treatment’s effectiveness.
Choice B rationale
Repositioning the newborn every 4 hours is not frequent enough. The newborn should be repositioned every 2 hours to ensure even exposure to the phototherapy light and to prevent pressure sores.
Choice C rationale
Removing the eye mask during feedings is correct. The eye mask should be removed during feedings to allow for bonding and to check for any signs of irritation or infection. This also ensures that the newborn’s eyes are protected from the phototherapy light when not under the lamp.
Choice D rationale
Supplementing feedings with glucose water is not recommended. Breast milk or formula should be used to ensure the newborn receives adequate nutrition and hydration. Glucose water does not provide the necessary nutrients and can interfere with breastfeeding.
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