The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?

Hemoglobin and hematocrit

Abdominal contour and bowel sounds

Heart rate and blood pressure

Urinary output and IV fluid intake

Answer and Explanation

The Correct Answer is C

A. Hemoglobin and hematocrit:
While monitoring hemoglobin and hematocrit levels is important for assessing blood loss, in the immediate situation of a developing perineal hematoma with severe pain and pressure, assessing vital signs takes precedence to identify any signs of circulatory compromise.

B. Abdominal contour and bowel sounds:
These assessments are not the first priority in this situation. The client's complaint of severe pain and pressure in the perineum indicates a localized issue that needs immediate attention.

C. Heart rate and blood pressure:
This is the correct answer. Assessing the client's heart rate and blood pressure is crucial to identify signs of shock or compromised circulation associated with the perineal hematoma.

D. Urinary output and IV fluid intake:
While monitoring urinary output and IV fluid intake is important for overall assessment, in the context of a perineal hematoma, assessing vital signs is more immediate to identify any signs of hemodynamic instability.

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Correct Answer is D

Explanation

A. Describe genetic testing protocols: While genetic testing may be part of prenatal care, it's not the primary concern for a pregnant woman addicted to heroin. The focus should be on managing the addiction and promoting a healthy pregnancy.

B. Discontinue the methadone right away: Abruptly stopping methadone, or any opioid replacement therapy, can lead to withdrawal symptoms, which can be harmful to both the mother and the fetus. It's crucial for pregnant individuals on methadone to work closely with their healthcare provider to manage the transition.

C. Sign up for group therapy sessions: Group therapy can be a supportive intervention for individuals dealing with addiction, but it should be part of a comprehensive treatment plan that includes medical management.

D. Start a prenatal care plan as soon as possible: This is the most appropriate choice. Prenatal care is crucial for monitoring the health of both the mother and the baby. Starting early allows healthcare providers to address any potential issues and provide necessary support. This includes managing the mother's opioid addiction through medications like methadone, which can be administered under close medical supervision during pregnancy.

A. Instruct the client to maintain bed rest for 24 hours. B. Encourage the client to increase her intake of oral fluids C. Schedule a visit with the healthcare provider today D. Verify the administered Rho(D) immune globulin's compatibility

Correct Answer is C

Explanation

A. Instruct the client to maintain bed rest for 24 hours:
There is no clear indication for bed rest based solely on a slightly elevated temperature. Bed rest is not a standard recommendation for this situation.

B. Encourage the client to increase her intake of oral fluids:
Increasing fluid intake is a general recommendation for mild elevations in temperature. Adequate hydration can support the body's natural response to infection or inflammation.

C. Schedule a visit with the healthcare provider today:
This option is a prudent choice. A temperature elevation after a medical procedure may indicate an infection, and it's appropriate to schedule a visit with the healthcare provider for further evaluation.

D. Verify the administered Rho(D) immune globulin's compatibility:
While verifying the compatibility of the administered medication is important, it is not the primary concern when a client reports an elevated temperature. In this context, addressing the temperature and potential infection takes precedence.

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Naxlex Comprehensive Predictor Exams

A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, "I just started taking methadone. Is there anything else I can do to make sure my baby is healthy? Which information should the nurse provide?

Correct Answer is D

Explanation

A pregnant client receives Rho(D) immune globulin after an amniocentesis. The day following the procedure the client calls the nurse to report a temperature of 99.8° F (37.67°C). Which action should the nurse implement?

Correct Answer is C

Explanation

The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?

A client at 18-weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?

The nurse is caring for a postpartal client who is exhibiting symptoms of a spinal headache 24 hours following delivery of a normal newborn. Prior to the anesthesiologist's arrival on the unit, which action should the nurse perform?

A 25-year-old client who had a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. The nurse knows that assessment for what complication has the highest priority for this client?

The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival?

The nurse is caring for a client who delivered 6 hours ago. Assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. Which action should the nurse take?

What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?