A nurse is assisting in the care of a group of clients who are postpartum. Which of the following clients should the nurse plan to see first?
A client who has a firm fundus following a vaginal birth and reports continuous perineal pain of 8 on a scale of 0 to 10
A client who is 30 hr postpartum and reports feeling tearful and overwhelmed
A client who is 12 hr postpartum and reports having to urinate frequently
A client who had a cesarean birth yesterday and reports burning incision pain of 5 on a scale of 0 to 10
The Correct Answer is A
Rationale:
A. A client who has a firm fundus following a vaginal birth and reports continuous perineal pain of 8 on a scale of 0 to 10: Although the fundus is firm, severe continuous perineal pain may indicate complications such as hematoma or infection, requiring immediate assessment and intervention to prevent worsening condition.
B. A client who is 30 hr postpartum and reports feeling tearful and overwhelmed: Postpartum emotional lability is common in this timeframe and generally not an immediate safety concern. The nurse should provide support but this client’s condition is not urgent.
C. A client who is 12 hr postpartum and reports having to urinate frequently: Frequent urination postpartum may be due to diuresis or normal bladder function return and is not typically urgent unless accompanied by other signs of infection or retention.
D. A client who had a cesarean birth yesterday and reports burning incision pain of 5 on a scale of 0 to 10: Moderate incision pain is expected after surgery and can be managed with analgesics; it does not require immediate intervention compared to potential perineal complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. New onset of hearing loss: Hearing loss is not a typical adverse effect of 0.9% sodium chloride infusion. It may occur with high-dose loop diuretics like furosemide but is unrelated to isotonic fluid administration or hyperparathyroidism management.
B. Kussmaul respirations: These are deep, rapid respirations seen in metabolic acidosis, particularly diabetic ketoacidosis. They are not associated with isotonic fluid infusion or calcium disturbances in hyperparathyroidism.
C. Hyperthermia: Elevated body temperature is not linked to 0.9% sodium chloride infusion. Hyperthermia may occur with infections or neurologic injury, but not as a direct consequence of isotonic fluid therapy.
D. Chvostek's sign: Chvostek's sign is a clinical indicator of hypocalcemia, which can occur as an adverse effect of 0.9% sodium chloride infusion in clients with hyperparathyroidism. Large volumes of saline increase calcium excretion, potentially leading to low serum calcium levels.
Correct Answer is D
Explanation
Rationale:
A. Give the dose of medication in the infant's bottle: Placing nystatin in a bottle may result in incomplete dosing, as the infant may not consume the full amount. This method also limits the medication's contact time with the affected mucosa, reducing its effectiveness.
B. Educate the caregiver to avoid breastfeeding: Breastfeeding should not be avoided unless the mother has signs of candidiasis on the breast. Instead, both mother and infant should be treated simultaneously if either shows symptoms to prevent reinfection.
C. Administer the medication before the infant's feeding: Administering nystatin before feeding may cause the medication to be washed away by milk, decreasing mucosal contact time. It is generally recommended after feeding to ensure prolonged exposure to the mucosa.
D. Distribute the medication on the infant's oral mucosa: Applying the suspension directly to the affected areas allows the antifungal to coat the mucosa thoroughly, maximizing effectiveness. It is the preferred method to treat oral candidiasis in infants.
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