A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to attend to first?

A client who reports changing their perineal pad every 4 hr.

A client who has a urine output of 750 mL in 6 hr.

A client who has 1+ deep tendon reflexes while receiving IV magnesium sulfate.

A client who reports abdominal cramping pain during breastfeeding.

Answer and Explanation

The Correct Answer is A

A. Changing a perineal pad only every 4 hours may indicate excessive bleeding or hemorrhage, which requires immediate assessment.
B. A urine output of 750 mL in 6 hours is within normal limits (about 125 mL/hr).
C. 1+ deep tendon reflexes indicate decreased reflexes, which is expected during magnesium sulfate therapy and generally not an immediate concern.
D. Abdominal cramping during breastfeeding is common due to uterine contractions and is usually not urgent.

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Correct Answer is B

Explanation

A. IV fluids should be administered cautiously in preeclampsia to avoid fluid overload; an IV bolus is not routinely indicated.
B. Monitoring for clonus is important, as it is a sign of increased neuromuscular irritability and risk of seizure in preeclampsia.
C. Misoprostol is used to manage postpartum bleeding but is not specific to preeclampsia management.
D. Fluid restriction is generally not recommended unless there are signs of fluid overload or other complications.

A. Monitor cervical dilation. B. Ask the client about the color of the water. C. Obtain the client's vaginal pH. D. Determine the fetal heart rate.

Correct Answer is D

Explanation

A. Monitoring cervical dilation is important but not the immediate priority.
B. Asking about the color of the amniotic fluid helps assess for meconium but is secondary.
C. Vaginal pH testing can help confirm rupture but is not the first action.
D. Determining the fetal heart rate is the priority to assess for signs of fetal distress immediately after rupture of membranes.

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A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to attend to first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is 1 hr postpartum and has preeclampsia without severe features. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse is admitting a client who is at 39 weeks of gestation and who states, "My water broke on the way to the hospital." Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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