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 C
Explanation
Choice A reason: To call for an immediate magnesium sulfate level is not the immediate action that the nurse should take, as it is a diagnostic test that requires a blood sample and a laboratory analysis, which can take time and delay the treatment. The nurse should first stop the infusion and notify the provider, as the client is showing signs of magnesium sulfate toxicity, which is a life-threatening condition that can cause respiratory depression, cardiac arrest, or coma.
Choice B reason: To prepare to administer hydralazine is not the immediate action that the nurse should take, as it is a pharmacological intervention that requires a prescription and an assessment of the blood pressure and the fetal status. Hydralazine is an antihypertensive drug that lowers the blood pressure and prevents the complications of severe preeclampsia, such as eclampsia, stroke, or organ damage. However, the client's blood pressure is not very high and is not the main problem at the moment.
Choice C reason: To discontinue the magnesium sulfate infusion is the immediate action that the nurse should take, as it is the first and most important intervention that can reverse the effects of magnesium sulfate and restore the neuromuscular function and the respiratory rate. Magnesium sulfate is a drug that prevents seizures and lowers the blood pressure in clients with severe preeclampsia, but it can also cause toxicity if the dose is too high or the infusion is too fast.
Choice D reason: To administer oxygen is not the immediate action that the nurse should take, as it is a supportive intervention that improves the oxygen delivery to the tissues and organs, but does not address the underlying cause of the respiratory depression, which is the magnesium sulfate toxicity. The nurse should administer oxygen only after stopping the infusion and assessing the oxygen saturation and the respiratory status.
Correct Answer is C
Explanation
Choice A reason: Molar pregnancy is a risk factor for hyperemesis gravidarum, as it is a gestational trophoblastic disease that causes an abnormal growth of the placenta and the production of high levels of human chorionic gonadotropin (hCG), which is a hormone that stimulates nausea and vomiting. Molar pregnancy can cause severe and persistent hyperemesis gravidarum, as well as vaginal bleeding, uterine enlargement, and preeclampsia.
Choice B reason: Previous history of hyperemesis gravidarum is a risk factor for hyperemesis gravidarum, as it suggests a genetic or physiological predisposition to the condition. Hyperemesis gravidarum is a severe form of nausea and vomiting that occurs in pregnancy, and it can cause dehydration, electrolyte imbalance, weight loss, and malnutrition. Hyperemesis gravidarum can recur in subsequent pregnancies, especially if the mother has the same partner, the same sex of the fetus, or a short interval between pregnancies.
Choice C reason: Oligohydramnios is not a risk factor for hyperemesis gravidarum, as it is a low level of amniotic fluid that surrounds the fetus. Oligohydramnios is not related to hyperemesis gravidarum, and it is not a cause or a consequence of it. Oligohydramnios can affect the fetal development and the delivery, as it can cause fetal growth restriction, cord compression, or meconium aspiration.
Choice D reason: Multiple fetal gestation is a risk factor for hyperemesis gravidarum, as it is a condition where the mother is carrying more than one fetus. Multiple fetal gestation can cause higher levels of hCG, estrogen, and progesterone, which are hormones that stimulate nausea and vomiting. Multiple fetal gestation can cause more severe and prolonged hyperemesis gravidarum, as well as preterm labor, anemia, and preeclampsia.
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