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.

Answer and Explanation

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.

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Correct Answer is ["C","D"]

Explanation

Choice C rationale

The client is tachycardic and has cool skin, indicating potential hypovolemia or shock due to excessive bleeding. Administering oxygen at 2 L/min via nasal cannula increases oxygen delivery to the tissues, improving cellular oxygenation and mitigating the effects of decreased circulating blood volume. This supports vital organ function and helps address tissue hypoxia, a common consequence of significant blood loss. Normal heart rate postpartum is 60-100 beats per minute.

Choice D rationale

Oxytocin is a uterotonic agent that stimulates uterine contractions. A boggy uterus and excessive bleeding are hallmark signs of uterine atony, the most common cause of postpartum hemorrhage. Initiating an infusion of oxytocin will promote uterine contraction, which compresses blood vessels and reduces blood loss, thereby addressing the underlying cause of the client's symptoms and preventing further hemorrhage. Normal lochia should be moderate in amount.

A. "It is important to gain 2 pounds per week throughout the rest of your pregnancy.”. B. "You can cause problems for your baby if you try to diet while pregnant.”. C. "It would be helpful for us to meet with the dietitian to see how they can help you meet and assess your nutritional needs.”. D. "You should eat an additional 700 calories per day while you are pregnant.”.

Correct Answer is C

Explanation

Choice A rationale

While weight gain is crucial during pregnancy, a blanket statement of 2 pounds per week is not universally appropriate. The recommended rate of weight gain varies based on the client's pre-pregnancy BMI and the trimester. Excessive or insufficient weight gain can lead to adverse maternal and fetal outcomes, including macrosomia or intrauterine growth restriction, highlighting the need for individualized nutritional guidance rather than a fixed weekly gain.

Choice B rationale

Dieting during pregnancy, especially restrictive calorie intake, can significantly compromise the nutrient supply to the developing fetus. Fetal growth and organogenesis are highly dependent on adequate maternal nutritional stores and daily nutrient intake. Inadequate nutrition can lead to low birth weight, premature birth, and long-term health complications for the infant, emphasizing the dangers of unguided dietary restrictions.

Choice C rationale

A dietitian possesses specialized knowledge in medical nutrition therapy and can provide personalized recommendations based on the adolescent's specific nutritional needs, gestational age, and pre-pregnancy weight. This collaborative approach ensures optimal maternal and fetal health by addressing any deficiencies, managing appropriate weight gain, and promoting healthy eating habits throughout the pregnancy, which is crucial for adolescent development and pregnancy outcomes.

Choice D rationale

The caloric needs of a pregnant adolescent increase in the second and third trimesters, but a fixed additional 700 calories per day may not be accurate for all individuals. Caloric requirements are dynamic and depend on pre-pregnancy weight, activity level, and the specific stage of gestation. Overestimation can lead to excessive weight gain, while underestimation can result in inadequate fetal growth, necessitating individualized assessment.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is 6 hours postpartum, tachycardic, and has cool skin. The client reports that they have been bleeding excessively. Which of the following actions should the nurse take?

Correct Answer is ["C","D"]

Explanation

A nurse is caring for an adolescent client who is at 24 weeks of gestation. The client's prepregnancy weight was within the recommended range for their height and they have gained 2.7 kg (6 lb) during the pregnancy. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

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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?