The RN has received a hand-off report.
Which client does the RN need to see first?
The client having trouble breastfeeding.
The client who had a postpartum hemorrhage 3 hours ago.
The client complaining of pain of 5 out of 10 and requesting pain medication.
The client with a history of pre-eclampsia and now has a BP of 130/90.
The Correct Answer is B
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While burping is important after feeding to prevent discomfort and regurgitation, it does not directly indicate overall health or hydration status.
Choice B rationale
Frequent loose yellow stools are typical in breastfed infants and indicate proper digestion and nutrition, but do not address overall hydration status directly.
Choice C rationale
Steady weight gain indicates good nutrition and overall health in the infant, reflecting adequate feeding and hydration.
Choice D rationale
Sleeping through the night is not an expectation for newborns, as they typically need frequent feeding due to small stomach capacity and rapid growth needs.
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale
A fundus midline and firm at the umbilicus is a normal postpartum finding and does not require reporting. It indicates that the uterus is contracting as expected to prevent postpartum hemorrhage.
Choice B rationale
Moderate lochia rubra without clots is expected in the immediate postpartum period and does not need to be reported. It is part of normal postpartum bleeding as the uterus sheds its lining.
Choice C rationale
A constant trickle of blood at the vagina postpartum could indicate a laceration or retained placental fragments and should be reported to the provider for further evaluation and management.
Choice D rationale
Hemoglobin levels can provide important information about the mother's blood loss during delivery. A low hemoglobin level could indicate significant blood loss and necessitates reporting.
Choice E rationale
An abnormal heart rate in a postpartum mother could be indicative of complications such as hemorrhage or infection and should be reported to the provider for further assessment.
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