The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?

Hemoglobin and hematocrit

Abdominal contour and bowel sounds

Heart rate and blood pressure

Urinary output and IV fluid intake

Answer and Explanation

The Correct Answer is C

A. Hemoglobin and hematocrit:
While monitoring hemoglobin and hematocrit levels is important for assessing blood loss, in the immediate situation of a developing perineal hematoma with severe pain and pressure, assessing vital signs takes precedence to identify any signs of circulatory compromise.

B. Abdominal contour and bowel sounds:
These assessments are not the first priority in this situation. The client's complaint of severe pain and pressure in the perineum indicates a localized issue that needs immediate attention.

C. Heart rate and blood pressure:
This is the correct answer. Assessing the client's heart rate and blood pressure is crucial to identify signs of shock or compromised circulation associated with the perineal hematoma.

D. Urinary output and IV fluid intake:
While monitoring urinary output and IV fluid intake is important for overall assessment, in the context of a perineal hematoma, assessing vital signs is more immediate to identify any signs of hemodynamic instability.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Insert a Foley catheter with a urimeter to monitor hourly output: This is a reasonable intervention because magnesium sulfate can affect renal function, and monitoring urinary output is essential. However, there's a more critical intervention to consider first.

B. Have calcium gluconate immediately available: This is the highest priority. Magnesium sulfate toxicity can lead to neuromuscular blockade, and calcium gluconate is the antidote. Having it readily available is crucial in case signs of magnesium toxicity (such as loss of deep tendon reflexes) appear.

C. Provide a quiet environment with subdued lighting: While maintaining a calm environment is generally important for clients on magnesium sulfate, it is not the highest priority in this situation.

D. Assess deep tendon reflexes (DTRs) every 4 hours: This is an important part of monitoring for magnesium sulfate toxicity. However, the immediate availability of calcium gluconate is the highest priority in case toxicity occurs.

A. Request a return demonstration of a diaper change B. Evaluate infant feeding techniques prior to discharge C. Provide the results of the infant's hearing test to the parents. D. Ensure that they have the pediatric clinic's phone number

Correct Answer is B

Explanation

A. Request a return demonstration of a diaper change:While it's useful for parents to know how to change a diaper, feeding is more critical for the infant’s health and development in the early days.

B. Evaluate infant feeding techniques prior to discharge:Ensuring that the parents understand how to properly feed their newborn is crucial. Proper feeding techniques are essential for the infant's nutrition, growth, and development. Issues with feeding can lead to dehydration, weight loss, and other health problems. Therefore, this is the most important intervention.

C. Provide the results of the infant's hearing test to the parents:Sharing the results of the hearing test is important, but it is less immediate compared to ensuring that the infant is properly fed.

D. Ensure that they have the pediatric clinic's phone number:
While it is important for parents to have contact information for follow-up care, it is secondary to ensuring they can feed their baby properly.

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

The nurse is preparing a young couple and their 24-hour-old infant for discharge from the hospital. In conducting discharge teaching, which intervention is most important for the nurse to implement?

Correct Answer is B

Explanation

After breast-feeding 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help change the newborn's diaper. As the mother begins the diaper change, the newborn spits up the breast milk. What action should the nurse implement first?

What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?

The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?

A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?

A client who had her first baby three months ago and is breastfeeding her infant tells the nurse that she is currently using the same diaphragm that she used before becoming pregnant. Which information should the nurse provide this client?

After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?