A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Which of the following assessments is the nurse's priority?

Pain Level

Amount of vaginal bleeding

Amount of urinary output

Fundal Height

Answer and Explanation

The Correct Answer is B

A. While assessing pain level is important for comfort management, it is not the highest priority in the immediate postpartum period.

B. The amount of vaginal bleeding is critical to assess during the fourth stage of labor to identify potential postpartum hemorrhage, especially with oxytocin administration.

C. Although urinary output is important to monitor for bladder distension, it does not take precedence over bleeding assessment.

D. Fundal height assessment is necessary to ensure the uterus is contracting effectively, but again, it is secondary to monitoring for bleeding.

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Correct Answer is B

Explanation

A. While offering choices can promote autonomy, allowing clients to choose their own mealtimes may lead to avoidance of meals and is not a structured approach needed for clients with anorexia nervosa.

B. Supervision during and after eating is critical in managing clients with anorexia nervosa to ensure they consume the necessary nutrients and to monitor for any harmful behaviors, such as purging.

C. Although providing choices can support autonomy, it may not be suitable for clients with anorexia nervosa, as they might choose low-calorie or unhealthy options.

D. Encouraging casual conversation about food can sometimes increase anxiety or lead to fixation on eating behaviors, making it an inappropriate strategy for this population.

A. Reason for the medication error B. Notification of the pharmacist C. Time the medication was given D. Completion of the incident report

Correct Answer is C

Explanation

A. The reason for the medication error should not be documented in the client's medical record due to potential legal implications; such information belongs in the incident report instead.

B. Documentation of notification to the pharmacist is relevant for the incident report but is not appropriate for the client's medical record.

C. The time the medication was given is an important detail that should be documented in the client's medical record as it affects the client's treatment and future medication administration.

D. Documenting the completion of the incident report should be done in the facility's quality assurance system, not in the client’s medical record.

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A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Which of the following assessments is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute mental health facility is planning care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the client's plan of care?

Correct Answer is B

Explanation

A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record?

Correct Answer is C

Explanation

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