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.

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A rationale:

Urinary retention is not a typical sign preceding the onset of labor. It's important to provide accurate information to the client, and this statement is not relevant to signs of impending labor.

Choice B rationale:

A decrease in vaginal discharge is not a typical sign preceding the onset of labor. The client should be informed about changes in cervical mucus, which is part of the mucus plug, but a decrease in vaginal discharge is not a specific indicator of impending labor.

Choice C rationale:

Experiencing a surge of energy is not a typical sign preceding the onset of labor. Some clients may report increased energy before labor, but it's not a reliable indicator for all.

Choice D rationale:

Having a weight gain of 0.5 to 1.5 kilograms is a sign that precedes the onset of labor. This weight gain is often attributed to increased amniotic fluid or edema and is associated with impending labor. This choice is the correct answer.

A. Maintain the newborn in a prone position. B. Apply lotion to the newborn's skin twice per day. C. Monitor the newborn's blood glucose level hourly. D. Monitor the baby's temperature while on phototherapy.

Correct Answer is D

Explanation

Choice A rationale:

Placing the newborn in a prone position is not recommended during phototherapy. The infant should be placed in a supine position to maximize the surface area exposed to the phototherapy lights.

Choice B rationale:

Applying lotion to the newborn's skin can interfere with phototherapy. It's important to keep the baby's skin free from lotions or ointments to ensure the effectiveness of the treatment.

Choice C rationale:

Monitoring the newborn's blood glucose level hourly is not a standard practice during phototherapy. The primary concern during phototherapy is monitoring the infant's bilirubin levels and ensuring proper eye protection.

Choice D rationale:

Monitoring the baby's temperature while on phototherapy is essential. Phototherapy can lead to heat loss, so maintaining the baby's temperature within the normal range is crucial to prevent complications. This choice is the correct answer.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about signs preceding the onset of labor with a client who is at 39 weeks of gestation.Which of the following statements should the nurse include?

Correct Answer is D

Explanation

A nurse is updating the plan of care for a newborn who is undergoing phototherapy.Which of the following actions should the nurse include in the plan?

Correct Answer is D

Explanation

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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?