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.
The Correct Answer is C
A. Changing a perineal pad every 4 hours is within expected postpartum norms for moderate bleeding. This client’s condition does not indicate an urgent issue.
B. A urine output of 750 mL over 6 hours is adequate (approximately 125 mL/hr) and does not signal immediate concern.
C. Deep tendon reflexes of 1+ in a client receiving IV magnesium sulfate may indicate early magnesium toxicity or impending hyporeflexia. Magnesium sulfate toxicity can lead to respiratory depression and cardiac arrest, making this the highest-priority client.
D. Abdominal cramping during breastfeeding is common due to uterine contractions (afterpains) and is generally expected and non-life-threatening. This can be addressed after assessing higher-priority clients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Abdominal assessment – The abdomen is tender to palpation, which is an abnormal finding and can indicate uterine activity or irritation associated with preterm labor or other complications.
B. Low back pain – This is a common early sign of preterm labor, especially when combined with uterine cramping and cervical changes.
C. Uterine contractions – Although the client has cramping, there is no specific documentation of palpable or monitor-confirmed contractions, so this cannot be definitively selected based on available data.
D. Abdominal cramping – This is concerning in a pregnant client at 30 weeks, especially in combination with cervical dilation, vaginal bleeding, and back pain.
E. Fundal height – At 30 weeks, a fundal height of 28 cm is within the normal range (should match gestational age ±2 cm). This is not abnormal.
F. Fetal heart rate – The scenario notes positive fetal movement but does not mention an abnormal FHR. Without abnormal FHR data, this cannot be selected.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
- Hyperbilirubinemia is a concern due to the presence of cephalohematoma (a firm, edematous area on the scalp that does not cross suture lines) and yellow sclera, both of which are indicators of increased bilirubin from red blood cell breakdown.
- The head assessment reveals these findings (scleral icterus and cephalohematoma), which directly support the risk.
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