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 D
Explanation
Choice A rationale
Placing a newborn in the right lateral position is not recommended as it increases the risk of suffocation and sudden infant death syndrome (SIDS)4.
Choice B rationale
Placing a newborn in the left lateral position is also not recommended for the same reasons as the right lateral position.
Choice C rationale
Placing a newborn in the prone position (on their stomach) significantly increases the risk of SIDS and is not recommended.
Choice D rationale
Placing a newborn in the supine position (on their back) is the safest position for sleep and is recommended to reduce the risk of SIDS4.
Correct Answer is A
Explanation
Choice A rationale
Placing the retainer clip at the level of the baby’s armpits is the correct position for the clip. This ensures that the harness straps are positioned correctly over the baby’s shoulders, providing optimal protection in the event of a crash.
Choice B rationale
Placing the baby in the car seat at a 90-degree angle is incorrect. Newborns should be placed in a rear-facing car seat at an angle of approximately 45 degrees to ensure their airway remains open and to provide proper support for their head and neck.
Choice C rationale
Turning the car seat to face forward when the baby weighs 15 pounds is not recommended. Babies should remain in a rear-facing car seat until they reach the maximum weight or height limit specified by the car seat manufacturer, typically around 2 years of age.
Choice D rationale
Placing a thick, soft pad behind the baby’s back is not recommended. Additional padding can interfere with the proper fit of the harness and reduce the effectiveness of the car seat in protecting the baby during a crash.
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