A nurse receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first?
A client who experienced a cesarean birth 4 hr ago and reports severe pain.
A client who has preeclampsia with a BP of 128/80 mm Hg
A client who is scheduled for discharge following a vaginal delivery without complications.
A client who experienced a vaginal birth 24 hr ago and reports a scant amount of lochia.
The Correct Answer is A
Choice A reason: This client should be seen first, as she has the most urgent and acute problem that requires immediate assessment and intervention. Severe pain after a cesarean birth can indicate infection, hemorrhage, or wound dehiscence, which are serious complications that can affect the client's recovery and well-being. The nurse should evaluate the client's pain level, location, and characteristics, and administer analgesics as prescribed. The nurse should also inspect the incision site, monitor the vital signs and lochia, and provide comfort measures.
Choice B reason: This client should be seen second, as she has a chronic and stable problem that requires ongoing monitoring and management. Preeclampsia is a hypertensive disorder of pregnancy that can cause complications, such as eclampsia, HELLP syndrome, or placental abruption. However, this client has a mild elevation of blood pressure that does not indicate severe preeclampsia or imminent eclampsia. The nurse should check the client's urine protein, reflexes, and edema, and report any signs of worsening condition to the provider.
Choice C reason: This client should be seen third, as she has a normal and expected outcome that requires routine education and discharge planning. A vaginal delivery without complications does not pose any significant risk or concern for the client or the newborn. The nurse should review the discharge instructions, such as follow-up appointments, self-care, breastfeeding, and warning signs, and answer any questions that the client may have.
Choice D reason: This client should be seen last, as she has a common and benign finding that requires reassurance and documentation. A scant amount of lochia after a vaginal birth is normal and expected, as it reflects the healing and involution of the uterus. The nurse should assess the color, odor, and consistency of the lochia, and provide perineal care and hygiene education to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Misoprostol is not the first line medication for postpartum hemorrhage, as it is a prostaglandin E1 analog that causes uterine contractions and cervical ripening. Misoprostol is used for the prevention and treatment of postpartum hemorrhage, but it is less effective and more side effects than oxytocin, which is the first line medication.
Choice B reason: Pitocin is the first line medication for postpartum hemorrhage, as it is a synthetic form of oxytocin, which is a hormone that stimulates uterine contractions and retraction. Pitocin is used for the induction and augmentation of labor, and the prevention and treatment of postpartum hemorrhage, as it reduces blood loss and enhances hemostasis.
Choice C reason: Hemabate is not the first line medication for postpartum hemorrhage, as it is a prostaglandin F2 alpha analog that causes uterine contractions and vasoconstriction. Hemabate is used for the treatment of postpartum hemorrhage, but it is contraindicated in clients with asthma, hypertension, or cardiac disease, as it can cause bronchospasm, hypertension, or cardiac arrhythmias.
Choice D reason: Methergine is not the first line medication for postpartum hemorrhage, as it is an ergot alkaloid that causes sustained uterine contractions and vasoconstriction. Methergine is used for the treatment of postpartum hemorrhage, but it is contraindicated in clients with hypertension, preeclampsia, or cardiac disease, as it can cause severe hypertension, cerebrovascular accidents, or myocardial infarction.
Correct Answer is C
Explanation
Choice A reason: Primigravida in spontaneous labor with preterm twins is not at the greatest risk for early postpartum hemorrhage, as preterm births are associated with lower blood loss and smaller placentas. However, this client may have other complications, such as preterm labor, premature rupture of membranes, or fetal growth restriction.
Choice B reason: Primiparous woman (G 2, P 1-0-0-1) being prepared for an emergency cesarean birth for fetal distress is not at the greatest risk for early postpartum hemorrhage, as cesarean births are associated with higher blood loss and larger incisions. However, this client may have other complications, such as infection, wound dehiscence, or thromboembolism.
Choice C reason: Multiparous woman (G 3, P 2-0-0-2) with an 8-hour labor is at the greatest risk for early postpartum hemorrhage, as multiparity and rapid labor are both risk factors for uterine atony, which is the most common cause of early postpartum hemorrhage. Uterine atony is a condition where the uterus fails to contract and retract after delivery, and can cause excessive bleeding and hypovolemic shock.
Choice D reason: Woman with severe preeclampsia on magnesium sulfate whose labor is being induced is not at the greatest risk for early postpartum hemorrhage, as preeclampsia and magnesium sulfate are both risk factors for late postpartum hemorrhage, which occurs after 24 hours of delivery. However, this client may have other complications, such as eclampsia, HELLP syndrome, or placental abruption.
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