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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: "I know I am at increased risk to develop type 2 diabetes." is a correct statement, because it indicates that the client understands the long-term implications of gestational diabetes. The client should be aware that gestational diabetes increases the risk of developing type 2 diabetes later in life, and that she should have regular screening and follow-up.

Choice B reason: "I will take my glyburide daily with breakfast." is a correct statement, because it indicates that the client understands the medication regimen for gestational diabetes. The client should take glyburide, a sulfonylurea that lowers blood glucose levels, as prescribed by the provider, and monitor her blood glucose levels before and after meals.

Choice C reason: "I will reduce my exercise schedule to 3 days a week." is an incorrect statement, because it indicates that the client does not understand the importance of physical activity for gestational diabetes. The client should exercise at least 30 minutes a day, 5 days a week, unless contraindicated by the provider. Exercise can help improve insulin sensitivity, lower blood glucose levels, and prevent excessive weight gain.

Choice D reason: "I should limit my carbohydrates to 50% of caloric intake." is a correct statement, because it indicates that the client understands the dietary guidelines for gestational diabetes. The client should consume a balanced diet that provides adequate but not excessive amounts of carbohydrates, protein, and fat, and that is consistent in carbohydrate intake throughout the day.

A. Using the words lost or gone rather than dead or died. B. Setting a firm time for ending the visit with the baby so that the parents know when to let go C. Encouraging the family not to give the baby a name D. Ensuring the baby is clothed or wrapped if the parents choose to visit with the baby

Correct Answer is D

Explanation

Choice A reason: This statement is incorrect, as it is not helpful to use euphemisms or avoid the words dead or died when talking about the loss of an infant. Using the words lost or gone can imply that the baby is not really dead, or that the baby can be found or returned, which can create confusion and denial in the family. Using the words dead or died can help the family to acknowledge and accept the reality of the loss, and to express their grief and emotions.

Choice B reason: This statement is incorrect, as it is not helpful to set a firm time for ending the visit with the baby, as it can make the parents feel rushed, pressured, or controlled. Setting a firm time for ending the visit can interfere with the parents' natural process of saying goodbye to the baby, and can prevent them from creating memories and bonding with the baby. The parents should be allowed to decide how long they want to spend with the baby, and to end the visit when they are ready.

Choice C reason: This statement is incorrect, as it is not helpful to encourage the family not to give the baby a name, as it can make the baby seem less real, less important, or less valued. Encouraging the family not to give the baby a name can deny the family's right to recognize and honor the baby as a person, and to establish a relationship and an identity with the baby. The family should be supported to give the baby a name, and to use the name when referring to the baby.

Choice D reason: This statement is correct, as it is helpful to ensure the baby is clothed or wrapped if the parents choose to visit with the baby, as it can make the baby look more comfortable, warm, and human. Ensuring the baby is clothed or wrapped can facilitate the parents' physical contact and interaction with the baby, and can enhance the parents' perception and memory of the baby. The parents should be offered to choose the clothing or the blanket for the baby, and to keep them as mementos.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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