An unlicensed assistive personnel (UAP) informs the charge nurse that a client who delivered a 7-pound (3,175 gram) infant 12 hours ago is experiencing a severe headache.
The client’s blood pressure is 110/70 mm Hg, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6° F (37° C). The client’s fundus is firm and one fingerbreadth above the umbilicus.
What should the charge nurse do first?
Notify the healthcare provider of the assessment findings.
Obtain a STAT hemoglobin and hematocrit.
Determine if the client received anesthesia during delivery.
Assign a practical nurse (PN) to reassess the client’s vital signs.
The Correct Answer is C
Choice A rationale
While notifying the healthcare provider of the assessment findings is important, it would not be the first action to take. The nurse should first gather more information about the client’s condition.
Choice B rationale
Obtaining a STAT hemoglobin and hematocrit would not be the first action to take. These tests could provide information about the client’s blood volume and potential for anemia, but they would not directly address the client’s complaint of a severe headache.
Choice C rationale
Determining if the client received anesthesia during delivery is the correct first action. A severe headache in the postpartum period can be a sign of a post-dural puncture headache, which can occur as a complication of spinal or epidural anesthesia.
Choice D rationale
Assigning a practical nurse (PN) to reassess the client’s vital signs would not be the first action to take. While ongoing monitoring of the client’s vital signs is important, the nurse should first investigate the potential cause of the client’s severe headache.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While conducting a gestational age assessment is important, it is not the priority in this situation.
Choice B rationale
Weighing and measuring the newborn are routine procedures, but they are not the priority when the newborn is showing signs of distress.
Choice C rationale
Evaluating the neonatal reflexes’ reactivity is an important part of the newborn assessment, but it is not the priority in this situation.
Choice D rationale
Performing a drug screen for cocaine is the priority in this situation. The symptoms described - shakiness, a fast heart rate, and high blood pressure - can be signs of neonatal abstinence syndrome, which can occur if the mother used certain drugs, such as cocaine, during pregnancy.
Correct Answer is B
Explanation
Choice A rationale
Cervical dilation is a sign of labor, but a dilation of 1 cm alone does not confirm active labor. It could be the early phase of labor or false labor.
Choice B rationale
Contractions that decrease with walking are typically associated with false labor. In true labor, contractions usually get stronger regardless of activity level.
Choice C rationale
While 2+ pitting edema in the lower extremities can be seen in pregnancy, it is not a reliable indicator of labor. It could be due to fluid retention or other conditions.
Choice D rationale
The status of the membranes (intact or ruptured) does not necessarily indicate whether a woman is in labor. Some women may experience membrane rupture before labor begins.
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