An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7-pound (3,175 gram) infant 12 hours ago is reporting 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. Which action should the charge nurse implement first?
Assign a practical nurse (PN) to reassess the client's vital signs.
Obtain a STAT hemoglobin and hematocrit
Notify the healthcare provider of the assessment findings
Determine if the client received anesthesia during delivery
The Correct Answer is C
A. Assign a practical nurse (PN) to reassess the client's vital signs:
While reassessing vital signs is important, the reported severe headache after delivery is a symptom that requires immediate attention. It's more appropriate for a licensed professional, such as the nurse or healthcare provider, to assess and decide the course of action.
B. Obtain a STAT hemoglobin and hematocrit:
While assessing hemoglobin and hematocrit can provide information about potential postpartum hemorrhage, it may not be the first action needed in this context. The severe headache suggests a possible neurological concern that should be addressed promptly.
C. Notify the healthcare provider of the assessment findings:
This is the most appropriate initial action. Severe headache after delivery, especially if the client had received anesthesia, could be indicative of post-dural puncture headache (PDPH). Prompt notification allows the healthcare provider to assess and decide on the necessary interventions.
D. Determine if the client received anesthesia during delivery:
Knowing the type of anesthesia is important for understanding potential complications. However, this information alone might not guide immediate actions. The focus should be on addressing the reported severe headache promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Chromosomal abnormalities:
While an ultrasound can sometimes identify structural abnormalities, it's not the primary tool for detecting chromosomal abnormalities. Genetic testing or procedures like amniocentesis are more specific for this purpose.
B. Sex and size of the infant:
An ultrasound is indeed used to determine the sex of the baby and assess its size and growth.
C. Lecithin-sphingomyelin ratio:
The lecithin-sphingomyelin ratio is typically assessed in tests related to fetal lung maturity, which is not the primary purpose of a routine ultrasound.
D. Fetal growth and gestational age:
This is one of the primary purposes of a routine ultrasound during pregnancy. It helps evaluate the baby's growth and ensures it aligns with the expected gestational age.
Correct Answer is C
Explanation
A. Assign a practical nurse (PN) to reassess the client's vital signs:
While reassessing vital signs is important, the reported severe headache after delivery is a symptom that requires immediate attention. It's more appropriate for a licensed professional, such as the nurse or healthcare provider, to assess and decide the course of action.
B. Obtain a STAT hemoglobin and hematocrit:
While assessing hemoglobin and hematocrit can provide information about potential postpartum hemorrhage, it may not be the first action needed in this context. The severe headache suggests a possible neurological concern that should be addressed promptly.
C. Notify the healthcare provider of the assessment findings:
This is the most appropriate initial action. Severe headache after delivery, especially if the client had received anesthesia, could be indicative of post-dural puncture headache (PDPH). Prompt notification allows the healthcare provider to assess and decide on the necessary interventions.
D. Determine if the client received anesthesia during delivery:
Knowing the type of anesthesia is important for understanding potential complications. However, this information alone might not guide immediate actions. The focus should be on addressing the reported severe headache promptly.
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