A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?
A client who gave birth 1 day ago and needs Rh(D) immune globulin.
A client who gave birth 3 days ago and reports breast fullness.
A client who gave birth 12 hr ago and reports an increase in urinary output.
A client who gave birth 8 hr ago and is saturating a perineal pad every hour.
The Correct Answer is D
Choice A rationale:
A client who gave birth 1 day ago and needs Rh(D) immune globulin should be seen soon but not necessarily first. Rh(D) immune globulin is administered to Rh-negative mothers with Rh- positive infants to prevent isoimmunization in future pregnancies.
Choice B rationale:
A client who gave birth 3 days ago and reports breast fullness is likely experiencing normal postpartum breast engorgement. This client can be attended to after the client with more urgent symptoms.
Choice C rationale:
A client who gave birth 12 hours ago and reports an increase in urinary output might have diuresis, which is a common postpartum physiological change. Although this requires assessment, it is not as urgent as the client in choice D.
Choice D rationale:
The nurse should see the client who gave birth 8 hours ago and is saturating a perineal pad every hour first because excessive postpartum bleeding could indicate hemorrhage, a potentially life-threatening complication. Immediate assessment and intervention are crucial in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Fresh cabbage leaves have been traditionally used as a home remedy to help alleviate pain and discomfort associated with breast engorgement. The coolness of the cabbage leaves can provide a soothing effect, and they may also have anti-inflammatory properties that help reduce swelling. However, it is important to note that this should be used as a complementary measure and not a substitute for medical treatment or advice if the engorgement is severe or persistent.
Correct Answer is B
Explanation
Choice A rationale:
Multiparity, or having given birth to multiple children, is associated with a decreased risk of ovarian cancer, not an increased risk. The protective effect may be due to the repeated ovulatory cycles that occur during pregnancy.
Choice B rationale:
Endometriosis is a condition where endometrial tissue grows outside the uterus. It is associated with an increased risk of ovarian cancer. The exact link is not fully understood, but it is believed that the inflammatory and hormonal changes in endometriosis may contribute to cancer development.
Choice C rationale:
Being under 40 years of age does not increase the risk of ovarian cancer. Advanced age is a known risk factor for ovarian cancer, with the highest incidence occurring in women over 60.
Choice D rationale:
Use of contraceptive medications, particularly oral contraceptives, has been shown to reduce the risk of ovarian cancer. These medications suppress ovulation and decrease the exposure of the ovaries to potential carcinogens.
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