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 A

Explanation

A. Elevating the affected leg is an important intervention for reducing swelling and promoting venous return, which can help alleviate discomfort and prevent further complications.

B. Placing cold compresses on the edematous area may provide temporary relief but is not a standard intervention for deep-vein thrombosis and could potentially harm tissue if applied for too long.

C. Restricting the client to 1 L of fluid per day is inappropriate, as adequate hydration is essential for maintaining good venous health and preventing further complications.

D. Maintaining the client on bed rest is not necessary; while rest is important, early ambulation is encouraged to promote circulation and prevent further clot formation unless contraindicated.

A. Compare the nurse's time management skills to the skills of coworkers. B. Review client satisfaction reports about the nurse's performance. C. Maintain regular notes about the nurse's time management skills. D. Ask another staff nurse to evaluate the nurse's time management skills.

Correct Answer is C

Explanation

A. Comparing the nurse's skills to coworkers may not provide an accurate evaluation as it can vary based on individual roles and responsibilities.

B. While client satisfaction reports can reflect overall performance, they may not specifically address time management skills.

C. Maintaining regular notes about the nurse's time management skills allows for ongoing assessment and provides concrete examples during the appraisal, making it the most effective method.

D. Asking another staff nurse for evaluation can introduce bias and may not provide a comprehensive view of the nurse's time management skills.

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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 is planning care for a client who is receiving heparin to treat a deep-vein thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is A

Explanation

A nurse manager is preparing a newly licensed nurse's performance appraisal. Which of the following methods should the nurse manager use to evaluate the nurse's time management skills?

Correct Answer is C

Explanation

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