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. Making a referral for social services is appropriate as they can assist the client with discharge planning, home care services, and resources for palliative care to support the client's wishes.

B. While it is important to explain the risks of leaving against medical advice, the priority is to support the client’s desire to go home, rather than focusing on the potential consequences at this moment.

C. Contacting the facility chaplain could be beneficial for emotional support, but it does not address the immediate need for facilitating the client’s wish to go home.

D. Encouraging the client to continue with inpatient care contradicts their expressed desire to be with family, which is a crucial aspect of their emotional well-being in this situation.

A. Have the client wear a surgical mask while being transported outside the room. B. Wear a surgical mask while providing care for the client. C. Restrict visitors from entering the client's room during hospitalization. D. Initiate contact precautions for the client upon admission.

Correct Answer is A

Explanation

A. Having the client wear a surgical mask while being transported outside the room is essential to prevent the transmission of TB to others. This minimizes exposure to airborne droplets.

B. Wearing a surgical mask while providing care for the client is not sufficient for preventing TB transmission; an N95 respirator is required to protect healthcare workers from inhaling airborne particles.

C. While restricting visitors may help limit exposure, it is not the most effective preventive measure compared to ensuring that the client wears a mask when out of their room.

D. Initiating contact precautions is not necessary for TB, as it primarily requires airborne precautions. Airborne isolation precautions should be followed, including the use of N95 respirators for healthcare workers and appropriate ventilation.

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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?

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