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.

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A rationale

Pumping breasts every few hours can stimulate milk production, which is not the goal for a formula-feeding mother.

Choice B rationale

Latching the baby on to feed for just a few minutes can also stimulate milk production, which is not the goal for a formula-feeding mother.

Choice C rationale

Changing breast pads often is a good practice for breastfeeding mothers to maintain hygiene and prevent infections, but it does not directly address the issue of painful, hard, and full breasts in a formula-feeding mother.

Choice D rationale

Wearing a form-fitting bra for the next couple of days can provide support and help reduce the discomfort associated with engorgement in a formula-feeding mother.

A. Assess deep tendon reflexes (DTRs) every 4 hours. B. Ensure calcium gluconate is immediately available. C. Insert a Foley catheter with a urimeter to monitor hourly output. D. Provide a quiet environment with subdued lighting.

Correct Answer is B

Explanation

Choice B rationale

When preparing to administer magnesium sulfate to a laboring client with elevated blood pressure, ensuring that calcium gluconate is immediately available is of the highest priority. Calcium gluconate is the antidote for magnesium sulfate toxicity, and having it readily available is crucial in case of an overdose.

Choice A rationale

While assessing deep tendon reflexes (DTRs) every 4 hours is an important part of monitoring a client receiving magnesium sulfate, it is not the most immediate priority when preparing to administer the medication.

Choice C rationale

Inserting a Foley catheter with a urimeter to monitor hourly output is an important part of the overall management of a client receiving magnesium sulfate. However, it is not the most immediate priority when preparing to administer the medication.

Choice D rationale

Providing a quiet environment with subdued lighting can contribute to the comfort of a laboring client. However, it is not the most immediate priority when preparing to administer magnesium sulfate.

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Naxlex Comprehensive Predictor Exams

A client, who is three days postpartum and formula feeding her newborn, reports experiencing painful, hard, and full breasts to the nurse.What recommendation should the nurse provide?

Correct Answer is D

Explanation

The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has risen from 110/60 mmHg to 140/90 mmHg.Which nursing protocol is of the highest priority?

Correct Answer is B

Explanation

After breastfeeding for 10 minutes on each breast, a new mother calls the nurse to the postpartum room to assist with changing the newborn’s diaper. As the mother begins the diaper change, the newborn regurgitates the breast milk. What should be the nurse’s first action?

A new mother, who is breastfeeding her 4-week-old infant and has type I diabetes, reports that her insulin needs have decreased since the birth of her child.What action should the nurse take?

A 25-year-old client experienced a severe postpartum hemorrhage following the vaginal birth of twins and is now transferred to the postpartum unit.What complication should the nurse prioritize during the client’s assessment?

The nurse is assessing a client who has been admitted in active labor. The cervix is dilated to 3 cm, 50% effaced, and the presenting part is at 0 station. An hour later, the client informs the nurse that she needs to use the restroom. What should be the nurse’s first course of action?

A nurse is evaluating a newborn who was delivered quickly at 38 weeks gestation. The newborn is shaky, has a fast heart rate, and high blood pressure.Which assessment action should the nurse prioritize?

A client at 28 weeks gestation is in preterm labor and it is not expected that the fetus will survive after delivery. What should be the nurse’s initial action?