A nurse on a postpartum unit is receiving change-of-shift report for 4 clients. Which of the following clients should the nurse plan to see first?

A client who gave birth 6 hr ago and just received a dose of methylergonovine

A client who gave birth 24 hr ago and has had a urinary output of 2800 mL

A client who is 3 days postpartum and reports bilateral breast fullness

A client who gave birth 8 hr ago and has moderate perineal edema

Answer and Explanation

The Correct Answer is A

Rationale:

A. A client who gave birth 6 hr ago and just received a dose of methylergonovine: Methylergonovine is used to control postpartum hemorrhage but can cause severe hypertension or other adverse effects. Close monitoring immediately after administration is critical to detect complications early.

B. A client who gave birth 24 hr ago and has had a urinary output of 2800 mL: Increased urinary output postpartum is common due to diuresis as the body eliminates excess fluid; this is not an urgent concern if the client is otherwise stable.

C. A client who is 3 days postpartum and reports bilateral breast fullness: Breast engorgement is common around this time and is expected. It can be managed with supportive measures and is not an immediate priority.

D. A client who gave birth 8 hr ago and has moderate perineal edema: Perineal edema is expected postpartum and usually resolves with routine care. Unless associated with severe pain or signs of infection, it does not require immediate attention.

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Correct Answer is D

Explanation

Rationale:

A. Boggy fundus 3 fingerbreadths above the umbilicus: A boggy uterus located above the umbilicus suggests uterine atony, which indicates that the oxytocin may not have been effective. This finding is not expected 30 minutes after administering oxytocin.

B. Client report of burning with urination: Burning during urination is unrelated to oxytocin administration and may point toward a urinary tract infection. It does not reflect the expected physiological response to uterine stimulation for controlling postpartum hemorrhage.

C. Saturation of perineal pad in 15 min: Continued excessive bleeding despite oxytocin administration indicates treatment failure and requires immediate intervention. Oxytocin should reduce uterine bleeding; thus, ongoing hemorrhage is not an expected finding.

D. Client report of uterine cramping: Uterine cramping is an expected response to oxytocin, which works by stimulating uterine smooth muscle contractions. These cramps help compress blood vessels at the placental site, reducing postpartum bleeding and promoting involution.

A. naloxone B. an additional dose of propofol C. oxygen 10 L/min via face mask D. acetaminophen E. an additional dose of fentanyl F. propranolol

Correct Answer is ["A","C"]

Explanation

Rationale:

• Naloxone: The client received fentanyl and is now showing signs of opioid-induced respiratory depression. Respiratory rate has decreased to 10/min and oxygen saturation to 87%. Naloxone will reverse the opioid’s effects and restore adequate respiratory effort.

• An additional dose of propofol: The client’s level of sedation is already too deep, as shown by low respiratory rate and blood pressure. Additional propofol would worsen central nervous system depression. It may cause complete apnea or cardiac compromise in this situation.

• Oxygen 10 L/min via face mask: The current oxygen flow via nasal cannula is insufficient given the client's low oxygen saturation. A face mask delivers higher oxygen concentration and flow. This is critical to correct hypoxia until the cause is reversed.

• Acetaminophen: There is no fever or current complaint of pain requiring antipyretics or analgesics. Administering acetaminophen now would not address the acute respiratory issue. It would delay more urgent and appropriate interventions.

• An additional dose of fentanyl: Administering more opioid would increase the risk of further respiratory depression. The client is already showing hypoventilation and declining oxygenation. More fentanyl would worsen sedation and endanger airway and breathing.

• Propranolol: The client is already hypotensive with a BP of 80/51 mm Hg and a heart rate of 68/min. Giving a beta blocker could severely depress cardiac output. This would increase the risk of organ hypoperfusion and cardiac arrest.

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A nurse on a postpartum unit is receiving change-of-shift report for 4 clients. Which of the following clients should the nurse plan to see first?

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