A nurse is receiving report about assigned clients at the start of his shift.
Which of the following clients should the nurse plan to attend to first?
A client who is scheduled for discharge in 2 hr following a laparoscopic tubal ligation.
A client who experienced a cesarean birth 4 hr ago and reports pain.
A client who has preeclampsia and a BP of 138/90 mm Hg.
A client who experienced a vaginal birth 24 hr ago and reports no bleeding.
The Correct Answer is B
Choice A rationale:
The nurse should prioritize the client's needs based on the severity of their condition. A client scheduled for discharge in 2 hours following a laparoscopic tubal ligation is generally stable and not in immediate need of care. Discharge planning can be done later.
Choice B rationale:
A client who experienced a cesarean birth 4 hours ago and reports pain requires immediate attention. Pain is a subjective symptom that should be addressed promptly to ensure the client's comfort and well-being. Uncontrolled pain can lead to complications and negatively affect the client's overall recovery.
Choice C rationale:
A client with preeclampsia and a blood pressure of 138/90 mm Hg is a concerning situation, but it is not the top priority in this scenario. Preeclampsia requires monitoring and intervention, but the client who just had a cesarean birth and is experiencing pain should be attended to first.
Choice D rationale:
A client who experienced a vaginal birth 24 hours ago and reports no bleeding is not a high-priority concern. Some clients may have minimal bleeding or none at all after a vaginal birth, and this can be normal. The absence of bleeding alone does not warrant immediate attention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
The statement, "I will eat every 6 hours throughout the day," is not the best approach for a client with hyperemesis gravidarum. Eating at regular intervals may not be well-tolerated in this condition, as frequent nausea and vomiting can make it challenging to keep food down.
Choice B rationale:
The statement, "I will drink water with my meals," is generally a good practice during pregnancy to stay hydrated. However, for a client with hyperemesis gravidarum, it may be advisable to separate fluid intake from meals to minimize the risk of triggering nausea.
Choice C rationale:
The statement, "I will limit my protein intake," is not a recommended approach, especially for a pregnant client. Protein is essential for fetal development, and limiting protein intake may not provide adequate nutrition for the growing fetus.
Choice D rationale:
The statement, "I will eat crackers before I get out of bed in the morning," is a good strategy for managing morning sickness, which is common in pregnancy. Eating plain crackers before getting out of bed can help alleviate nausea and stabilize blood sugar levels.
Correct Answer is C
Explanation
The correct answer is choice C: The stump should fall off in 10 to 14 days.
Choice A rationale: Cleanse the area around the cord with baby oil each day. This is incorrect because cleansing with baby oil is not recommended. Instead, the nurse should advise the client to clean the area with water and a mild soap if necessary
Choice B rationale: Do not immerse the newborn's abdomen in water until the cord is dry. This is incorrect because sponge baths are recommended until the umbilical cord falls off, and immersion in water is not strictly prohibited
Choice C rationale: The stump should fall off in 10 to 14 days. This is correct because the umbilical cord stump typically falls off within 10 to 14 days after birth
Choice D rationale: Protect the cord by covering it with the newborn's diaper. This is incorrect because the diaper should be folded down below the umbilical cord to keep it dry and exposed to air
In conclusion, the nurse should reinforce that the umbilical cord stump should fall off within 10 to 14 days after birth. It is essential to provide accurate information and instructions for proper cord care to prevent infection and promote healing
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