A nurse receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first?
A client who experienced a cesarean birth 4 hr ago and reports severe pain.
A client who has preeclampsia with a BP of 128/80 mm Hg
A client who is scheduled for discharge following a vaginal delivery without complications.
A client who experienced a vaginal birth 24 hr ago and reports a scant amount of lochia.
The Correct Answer is A
Choice A reason: This client should be seen first, as she has the most urgent and acute problem that requires immediate assessment and intervention. Severe pain after a cesarean birth can indicate infection, hemorrhage, or wound dehiscence, which are serious complications that can affect the client's recovery and well-being. The nurse should evaluate the client's pain level, location, and characteristics, and administer analgesics as prescribed. The nurse should also inspect the incision site, monitor the vital signs and lochia, and provide comfort measures.
Choice B reason: This client should be seen second, as she has a chronic and stable problem that requires ongoing monitoring and management. Preeclampsia is a hypertensive disorder of pregnancy that can cause complications, such as eclampsia, HELLP syndrome, or placental abruption. However, this client has a mild elevation of blood pressure that does not indicate severe preeclampsia or imminent eclampsia. The nurse should check the client's urine protein, reflexes, and edema, and report any signs of worsening condition to the provider.
Choice C reason: This client should be seen third, as she has a normal and expected outcome that requires routine education and discharge planning. A vaginal delivery without complications does not pose any significant risk or concern for the client or the newborn. The nurse should review the discharge instructions, such as follow-up appointments, self-care, breastfeeding, and warning signs, and answer any questions that the client may have.
Choice D reason: This client should be seen last, as she has a common and benign finding that requires reassurance and documentation. A scant amount of lochia after a vaginal birth is normal and expected, as it reflects the healing and involution of the uterus. The nurse should assess the color, odor, and consistency of the lochia, and provide perineal care and hygiene education to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect, as it is not helpful to use euphemisms or avoid the words dead or died when talking about the loss of an infant. Using the words lost or gone can imply that the baby is not really dead, or that the baby can be found or returned, which can create confusion and denial in the family. Using the words dead or died can help the family to acknowledge and accept the reality of the loss, and to express their grief and emotions.
Choice B reason: This statement is incorrect, as it is not helpful to set a firm time for ending the visit with the baby, as it can make the parents feel rushed, pressured, or controlled. Setting a firm time for ending the visit can interfere with the parents' natural process of saying goodbye to the baby, and can prevent them from creating memories and bonding with the baby. The parents should be allowed to decide how long they want to spend with the baby, and to end the visit when they are ready.
Choice C reason: This statement is incorrect, as it is not helpful to encourage the family not to give the baby a name, as it can make the baby seem less real, less important, or less valued. Encouraging the family not to give the baby a name can deny the family's right to recognize and honor the baby as a person, and to establish a relationship and an identity with the baby. The family should be supported to give the baby a name, and to use the name when referring to the baby.
Choice D reason: This statement is correct, as it is helpful to ensure the baby is clothed or wrapped if the parents choose to visit with the baby, as it can make the baby look more comfortable, warm, and human. Ensuring the baby is clothed or wrapped can facilitate the parents' physical contact and interaction with the baby, and can enhance the parents' perception and memory of the baby. The parents should be offered to choose the clothing or the blanket for the baby, and to keep them as mementos.
Correct Answer is B
Explanation
Choice A reason: Blunt force trauma is a possible risk factor for placental abruption, which is a condition where the placenta detaches from the uterine wall and causes bleeding, pain, and fetal distress. However, blunt force trauma is not the most common risk factor, as it accounts for only a small percentage of cases. The most common causes of blunt force trauma are motor vehicle accidents, falls, or domestic violence.
Choice B reason: Hypertension is the most common risk factor for placental abruption, as it affects about 50% of cases. Hypertension can cause vasospasm and reduced blood flow to the placenta, which can weaken the attachment and lead to separation. Hypertension can be chronic, gestational, or related to preeclampsia.
Choice C reason: Gestational diabetes mellitus is not a risk factor for placental abruption, but rather a condition where the client develops high blood sugar levels during pregnancy and can cause complications, such as macrosomia, polyhydramnios, or neonatal hypoglycemia. Gestational diabetes mellitus does not affect the placental attachment or function.
Choice D reason: Cigarette smoking is a risk factor for placental abruption, as it can cause vasoconstriction and reduced oxygen delivery to the placenta, which can impair its growth and development. However, cigarette smoking is not the most common risk factor, as it affects about 25% of cases.
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