A nurse on the postpartum unit is assisting with the care of a group of clients.
Which of the following clients should the nurse plan to see first?
A client who gave birth 18 hours ago and has a temperature of 37.8°C (100°F).
A G2P1 client who gave birth 8 hours ago and reports abdominal pain during breastfeeding.
A client who gave birth 24 hours ago and reports not yet having a bowel movement.
A G5P4 client who gave birth 6 hours ago and has saturated one perineal pad over the past 2 hours.
The Correct Answer is D
Choice A rationale
A temperature of 37.8°C (100°F) 18 hours postpartum is slightly elevated but not necessarily indicative of a serious issue. It may require monitoring but is not the most urgent concern.
Choice B rationale
Abdominal pain during breastfeeding 8 hours postpartum is a common experience due to uterine contractions. While it may cause discomfort, it is not typically an urgent concern.
Choice C rationale
Not having a bowel movement 24 hours postpartum is not uncommon and does not usually require immediate attention. It can be addressed with dietary changes and other interventions.
Choice D rationale
Saturating one perineal pad over 2 hours 6 hours postpartum in a G5P4 client indicates a potential risk of postpartum hemorrhage. This is a more urgent concern that requires immediate assessment and intervention to prevent complications. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A
Choice A rationale: Using a breast pump helps maintain milk supply and prevent milk stasis, which reduces the risk of developing mastitis. Mastitis is an infection of the breast tissue that can cause pain, swelling, warmth, and redness.
Choice B rationale: Covering breasts immediately after feedings does not directly prevent mastitis. Proper hygiene and ensuring complete breast emptying are more effective measures for preventing mastitis. Covering may trap moisture and bacteria, potentially leading to infection.
Choice C rationale: Wearing an underwire bra between feedings can restrict milk flow and cause clogged ducts, increasing the risk of mastitis. Non-restrictive, well-fitting bras are recommended to ensure proper milk drainage and breast comfort.
Choice D rationale: Washing nipples with soap and water daily can strip natural oils, causing dryness and cracks. Cracked nipples are entry points for bacteria, increasing mastitis risk. Instead, cleaning with plain water is recommended to maintain nipple integrity.
Correct Answer is A
Explanation
Choice A rationale
Taking a break and walking at least once every hour during long trips helps improve circulation and reduces the risk of blood clots, which is particularly important during pregnancy.
Choice B rationale
Wearing the shoulder harness snug across the stomach is incorrect. The shoulder harness should be worn across the chest and between the breasts to avoid pressure on the abdomen.
Choice C rationale
Positioning the lap belt across the navel is incorrect. The lap belt should be placed under the belly, across the hips and pelvic bone, to avoid pressure on the uterus.
Choice D rationale
Moving the car seat forward, close to the steering wheel, is not recommended. Pregnant women should maintain a safe distance from the steering wheel to avoid injury in case of an accident.
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