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 ["B","E"]
Explanation
A. Maternal Rh factor – The mother is O positive. Rh incompatibility is not a concern here because both mother and newborn are likely Rh positive, and no information suggests Rh incompatibility.
B. Gestational age – The newborn was born at 36 weeks and 4 days, which is considered late preterm and places the infant at increased risk for complications such as respiratory distress, jaundice, hypoglycemia, and feeding difficulties.
C. Apgar scores – Scores of 7 at 1 minute and 8 at 5 minutes are within the normal range and not indicative of distress or a complication risk.
D. Weight – A birth weight of 3,062 g (6 lb 12 oz) is appropriate for gestational age and not a risk factor.
E. Type of birth – Operative vaginal birth using a vacuum extractor increases the risk for complications like cephalohematoma, which is noted in the assessment (firm, edematous scalp area with ecchymosis not crossing suture lines). This can contribute to jaundice.
F. Length – A length of 48 cm (19 in) is appropriate for gestational age and not a risk factor.
Correct Answer is B
Explanation
A. A pain rating of 3 is relatively mild and does not indicate urinary retention.
B. A boggy, deviated fundus suggests bladder distention, which can occur when the bladder is full and displaces the uterus. This is an indication for straight catheterization to relieve urinary retention.
C. Moderate lochia rubra is expected 4 hours postpartum and does not indicate urinary retention.
D. While edema and bruising are common after delivery, they do not alone indicate a need for catheterization.
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