A client is admitted to the postpartum unit and tells the nurse she had rheumatic fever as a child, which resulted in some "heart damage." The nurse knows that this client is at particular risk for developing heart failure during the immediate postpartum period. Based on this client's history, which nursing problem has the highest priority?

Sleep deprivation.

Fluid volume excess

Nausea and vomiting

Risk for infection.

Answer and Explanation

The Correct Answer is B

A. Sleep deprivation:

While sleep is important for overall well-being, it may not be the top priority in this case. Fluid volume excess, given the client's cardiac history, poses a more immediate threat to health.

B. Fluid volume excess:

Clients with heart damage are prone to heart failure, and managing fluid balance is crucial. Excess fluid can worsen cardiac function, making this the priority concern.

C. Nausea and vomiting:

While nausea and vomiting are significant concerns, they might not be as directly related to the client's cardiac history as fluid volume excess. However, if severe, it could contribute to fluid imbalance.

D. Risk for infection:

Infection is a concern for postpartum clients, but in this case, the client's history of rheumatic fever and heart damage takes precedence. The priority is to prevent complications related to heart failure.

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Correct Answer is D

Explanation

A. Review the fetal heart rate pattern: Checking the fetal heart rate (FHR) pattern is crucial during labor to ensure the baby is tolerating labor well and there are no signs of fetal distress. However, when the client expresses a need to use the bathroom, this may not be the immediate action required.

B. Check the pH of the vaginal fluid: Checking the pH of the vaginal fluid is not typically an initial action when a laboring client expresses a need to go to the bathroom. Monitoring the pH may be relevant for various reasons, but it's not a primary consideration in this context.

C. Determine cervical dilation: The initial examination revealed the cervix was 3 cm dilated. While reassessing the cervical dilation could provide information about the progress of labor, it may not be the most immediate action needed when the client wants to use the bathroom.

D. Palpate the client's bladder: This is the most relevant action when a laboring client expresses a desire to go to the bathroom. Palpating the bladder can help determine if it's full, which is important because a full bladder might impede labor progress or cause discomfort during contractions.

A. Inspect the client's face for edema B. Ascertain the frequency of headaches C. Evaluate for history of cluster headaches D. Observe and time client's contractions

Correct Answer is A

Explanation

Inspect the client's face for edema:
Elevated blood pressure during pregnancy may be a sign of preeclampsia, a condition that can involve fluid retention. Edema, particularly in the face, is one of the signs that the nurse should assess for in determining if preeclampsia is a concern.

Ascertain the frequency of headaches:
Frequent headaches can be a symptom of various conditions, including preeclampsia. Gathering information about the frequency and characteristics of headaches can provide additional data for assessing the client's overall condition.

Evaluate for history of cluster headaches:
Cluster headaches, while severe, are not typically associated with elevated blood pressure during pregnancy. This information might not be directly relevant to the client's current symptoms.

Observe and time client's contractions:
Contractions are not typically associated with nausea, vomiting, or elevated blood pressure during pregnancy. This action may not address the primary concerns presented by the client.

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Naxlex Comprehensive Predictor Exams

The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated 50% effaced, and the presenting part is at 0 station. An hour later. she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?

Correct Answer is D

Explanation

A client who is 32 weeks gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?

Correct Answer is A

Explanation

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?

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