An unlicensed assistive personnel (UAP) informs the charge nurse that a client who delivered a 7-pound (3,175 gram) infant 12 hours ago is experiencing a severe headache.
The client’s blood pressure is 110/70 mm Hg, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6° F (37° C). The client’s fundus is firm and one fingerbreadth above the umbilicus.
What should the charge nurse do first?
Notify the healthcare provider of the assessment findings.
Obtain a STAT hemoglobin and hematocrit.
Determine if the client received anesthesia during delivery.
Assign a practical nurse (PN) to reassess the client’s vital signs.
The Correct Answer is C
Choice A rationale
While notifying the healthcare provider of the assessment findings is important, it would not be the first action to take. The nurse should first gather more information about the client’s condition.
Choice B rationale
Obtaining a STAT hemoglobin and hematocrit would not be the first action to take. These tests could provide information about the client’s blood volume and potential for anemia, but they would not directly address the client’s complaint of a severe headache.
Choice C rationale
Determining if the client received anesthesia during delivery is the correct first action. A severe headache in the postpartum period can be a sign of a post-dural puncture headache, which can occur as a complication of spinal or epidural anesthesia.
Choice D rationale
Assigning a practical nurse (PN) to reassess the client’s vital signs would not be the first action to take. While ongoing monitoring of the client’s vital signs is important, the nurse should first investigate the potential cause of the client’s severe headache.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale
Return of lochia rubra, or bright red bleeding, is not a sign of postpartum depression. It is a normal part of the postpartum period and can last for several weeks after childbirth.
Choice B rationale
Engorged, painful breasts can be a sign of breastfeeding complications, but they are not a sign of postpartum depression. They are a common experience for many women as their milk comes in after childbirth.
Choice C rationale
Difficulty falling asleep, even when the baby is sleeping, can be a sign of postpartum depression. Sleep disturbances are common among women with postpartum depression.
Choice D rationale
Decreased appetite can be a sign of postpartum depression. Changes in eating habits, such as eating too little or too much, are common symptoms of depression.
Choice E rationale
Feelings of sadness that last for more than two weeks after childbirth can be a sign of postpartum depression. While many women experience “baby blues” in the first few weeks after childbirth, prolonged feelings of sadness can indicate a more serious issue.
Correct Answer is B
Explanation
Choice A rationale
Calcium is essential for the development of fetal bones and teeth, but it is not specifically linked to preventing neural tube defects like anencephaly.
Choice B rationale
Folic acid is vital for preventing neural tube defects, including anencephaly. It’s recommended for women of childbearing age and especially during the early stages of pregnancy.
Choice C rationale
Vitamin D is important for bone health, but its primary function is not directly related to preventing neural tube defects like anencephaly.
Choice D rationale
Iron is crucial for preventing anemia in pregnancy, supporting increased blood volume. However, it is not directly associated with preventing neural tube defects.
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