A nurse is caring for a group of clients who are postpartum.
Which of the following clients is at an increased risk for a fall?
A client who has an indwelling urinary catheter.
A client who has a second-degree perineal laceration.
A client who is saturating a perineal pad every 5 to 6 hours.
A client who is experiencing breast engorgement.
The Correct Answer is A
Choice A rationale
A client with an indwelling urinary catheter is at increased risk for falls due to several factors. The catheter tubing can create a tripping hazard, and the associated bag can restrict mobility. Furthermore, the presence of a catheter can lead to postural hypotension upon ambulation due to prolonged bedrest or fluid shifts, impairing balance and increasing fall risk.
Choice B rationale
A second-degree perineal laceration causes localized pain and discomfort, potentially leading to a cautious gait. While this can affect mobility, it does not inherently present the same level of tripping hazard or systemic physiological changes like orthostatic hypotension that are associated with an indwelling catheter, making the fall risk comparatively lower.
Choice C rationale
Saturating a perineal pad every 5 to 6 hours indicates a normal lochial flow. Excessive bleeding (saturating a pad in less than an hour) would be a significant risk factor for hypovolemia and subsequent orthostatic hypotension, thus increasing fall risk. Normal flow, however, does not directly contribute to an increased fall risk.
Choice D rationale
Breast engorgement causes discomfort and fullness in the breasts, which can limit arm movement and potentially interfere with comfortable positioning. While uncomfortable, breast engorgement itself does not typically lead to systemic physiological changes like orthostatic hypotension or create physical impediments that directly increase the risk of a fall.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
The nurse should identify that the client is at the greatest risk for preterm birth due to fetal fibronectin.
Rationale for correct answers:
Fetal fibronectin (fFN) is a glycoprotein found at the maternal-fetal interface, serving as a “biological glue” between the chorion and decidua. Normally, fFN is not detectable in cervicovaginal secretions between 22 and 34 weeks gestation. A level greater than 0.05 mcg/mL, such as this client’s 0.09 mcg/mL, signals disruption of the fetal membranes and an increased risk of preterm birth. It has a high negative predictive value, so a positive result strongly suggests premature labor risk, prompting interventions like tocolytics and corticosteroids to promote fetal lung maturity.
Rationale for incorrect Response 1 options:
Precipitous labor is rapid labor lasting under 3 hours from onset to delivery. Fetal fibronectin does not predict the speed of labor but the risk of preterm onset. This client’s labor is not precipitous based on exam and monitoring.
Chorioamnionitis is an intra-amniotic infection usually accompanied by maternal fever, uterine tenderness, and fetal tachycardia. Fetal fibronectin does not indicate infection.
Preeclampsia involves hypertension and proteinuria after 20 weeks and is unrelated to fetal fibronectin levels.
Rationale for incorrect Response 2 options:
Nitrazine and ferning tests assess membrane rupture. Both are negative here, indicating intact membranes, which does not exclude preterm labor but means premature rupture of membranes (PPROM) is unlikely.
Blood pressure measurements evaluate maternal hemodynamics, not risk of preterm birth.
Take-home points:
- Elevated fetal fibronectin (>0.05 mcg/mL) between 22-34 weeks indicates increased risk for preterm birth.
- Negative nitrazine and ferning tests suggest membranes are intact, helping differentiate preterm labor from PPROM.
- Preterm labor risk should be differentiated from precipitous labor, infection (chorioamnionitis), and hypertensive disorders like preeclampsia.
- Early identification of preterm labor risk allows timely administration of tocolytics and corticosteroids to improve neonatal outcomes.
Correct Answer is A
Explanation
Choice A rationale
Magnesium sulfate toxicity causes central nervous system depression, including respiratory depression. A respiratory rate of 12 breaths/min indicates that the respiratory depression has resolved, suggesting the calcium gluconate, a magnesium antagonist, has effectively reversed the neuromuscular blockade caused by magnesium. A normal respiratory rate is 12-20 breaths/min.
Choice B rationale
Absent deep tendon reflexes (DTRs) are a sign of magnesium sulfate toxicity due to its depressant effect on neuromuscular transmission. If calcium gluconate were effective, DTRs would return to normal or become less diminished, indicating resolution of magnesium's inhibitory effects on the nervous system.
Choice C rationale
Slurred speech is a neurological symptom associated with magnesium sulfate toxicity, reflecting central nervous system depression. If calcium gluconate were effective in reversing the toxicity, slurred speech would improve or resolve as the central nervous system depression diminishes.
Choice D rationale
Urine output of 22 mL/hr indicates oliguria, which can be a sign of worsening preeclampsia or kidney dysfunction, and is not an indicator of effective calcium gluconate administration for magnesium toxicity. Adequate urine output (typically >30 mL/hr) is essential for magnesium excretion and overall renal function.
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