A nurse from a medical-surgical unit is floating to a postpartum unit. Which of the following clients is an appropriate assignment for the nurse to accept?
A client who had a cesarean delivery 24 hr ago
A client who is receiving oxytocin for uterine atony
A client who will be breastfeeding for the first time
A client who underwent removal of a retained placenta
The Correct Answer is A
A. A client who had a cesarean delivery 24 hr ago: A medical-surgical nurse has the knowledge and skills to monitor a postoperative client, including assessment of vital signs, pain management, incision care, and early ambulation. This assignment is appropriate because it involves standard post-surgical care that aligns with the nurse’s current competencies.
B. A client who is receiving oxytocin for uterine atony: Oxytocin administration for active uterine atony requires rapid recognition of hemorrhage, titration of medication, and frequent maternal and fetal monitoring. A nurse unfamiliar with postpartum complications may not safely manage this high-risk situation, making it inappropriate for a float assignment.
C. A client who will be breastfeeding for the first time: Assisting a new mother with initial breastfeeding requires specialized knowledge of latch techniques, positioning, and management of common breastfeeding issues. A nurse without postpartum or lactation experience may not provide safe or effective guidance, making this assignment unsuitable.
D. A client who underwent removal of a retained placenta: This client is at high risk for postpartum hemorrhage and requires frequent assessment and immediate intervention if complications occur. Management of such a high-acuity postpartum client exceeds the typical scope of a medical-surgical nurse without specialized obstetric experience.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Poor feeding: Newborns experiencing neonatal abstinence syndrome (NAS) often have neurologic irritability and gastrointestinal dysfunction caused by withdrawal from in utero exposure to opioids or other substances. Poor feeding, along with vomiting, diarrhea, and excessive sucking, is a common manifestation.
B. Weak cry: Infants with NAS typically have a high-pitched, shrill, or incessant cry due to central nervous system hyperactivity. A weak or soft cry is not characteristic and may suggest other neurologic conditions rather than withdrawal.
C. Hypotonia: NAS usually presents with hypertonia, jitteriness, and tremors. Hypotonia is not a typical finding; decreased muscle tone may indicate a different neurologic or metabolic disorder.
D. Absent Moro reflex: The Moro reflex is generally intact or exaggerated in infants with NAS because of increased neuromuscular irritability. An absent reflex is more consistent with severe neurologic impairment rather than substance withdrawal.
Correct Answer is A
Explanation
A. Call EMS if a seizure lasts 5 min or more: Prolonged seizures lasting 5 minutes or longer can progress to status epilepticus, a medical emergency that requires immediate intervention to prevent hypoxia, brain injury, or other complications. Parents should be instructed to activate emergency services promptly if seizures exceed this duration or if multiple seizures occur without full recovery.
B. Restrain the child at the onset of the seizure: Physical restraint during a seizure can cause injury to both the child and caregiver. Safe seizure management includes protecting the child from nearby hazards while allowing the seizure to run its course, rather than attempting to forcibly stop movements.
C. Offer the child a bubble bath every evening: Bubble baths are not specifically related to seizure safety or management. While baths can be part of routine hygiene, parents should avoid leaving the child unattended in water due to the risk of drowning during a seizure episode.
D. Place the child in a prone position during the seizure: Placing a child in the prone position increases the risk of airway obstruction and aspiration. Standard seizure safety includes positioning the child on their side (lateral recumbent) to maintain airway patency and facilitate drainage of secretions.
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