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: This statement is incorrect, as surfactant is not an antibiotic and does not treat infections. Surfactant is a substance that is naturally produced by the lungs to reduce the surface tension and prevent the alveoli from collapsing. Premature infants may have insufficient surfactant, which can cause RDS.
Choice B reason: This statement is partially true, as surfactant can help reduce episodes of periodic apnea, which is a condition where the newborn stops breathing for more than 20 seconds. However, this is not the main purpose of surfactant therapy, and other interventions, such as oxygen, ventilation, and caffeine, may be needed to treat apnea.
Choice C reason: This statement is correct, as surfactant improves the ability of the baby's lungs to exchange oxygen and carbon dioxide, which are essential for life. Surfactant therapy can improve the lung function, reduce the need for mechanical ventilation, and prevent complications, such as bronchopulmonary dysplasia and pulmonary hemorrhage.
Choice D reason: This statement is false, as surfactant does not affect the level of sedation in the newborn. Surfactant is administered through an endotracheal tube, which may require sedation to reduce discomfort and agitation. The nurse should monitor the newborn's vital signs, oxygen saturation, and pain level during and after the procedure.
Correct Answer is D
Explanation
Choice A reason: Thrombophlebitis is a condition where a blood clot forms in a vein and causes inflammation and pain. The risk factors for thrombophlebitis include immobility, dehydration, obesity, smoking, and cesarean birth. This client is not at increased risk for thrombophlebitis based on the information given.
Choice B reason: Retained placental fragments are pieces of the placenta that remain in the uterus after delivery and can cause bleeding, infection, or uterine subinvolution. The risk factors for retained placental fragments include placenta previa, placenta accreta, manual removal of the placenta, and incomplete separation of the placenta. This client is not at increased risk for retained placental fragments based on the information given.
Choice C reason: Puerperal infection is an infection of the reproductive tract that occurs within six weeks after delivery and can cause fever, malaise, abdominal pain, and foul-smelling lochia. The risk factors for puerperal infection include prolonged rupture of membranes, prolonged labor, multiple vaginal examinations, operative delivery, and retained placental fragments. This client is not at increased risk for puerperal infection based on the information given.
Choice D reason: Uterine atony is a condition where the uterus fails to contract and retract after delivery and can cause excessive bleeding, hypovolemic shock, and hemorrhage. The risk factors for uterine atony include overdistension of the uterus, prolonged labor, oxytocin use, anesthesia, and trauma. This client is at increased risk for uterine atony due to the large size of the newborn, which can overstretch the uterus and impair its ability to contract.
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