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A nurse has just received change-of-shift report about four clients who are postpartum.

 

Which of the following clients should the nurse plan to see first?

A.

A client whose labor lasted for 6 hours.

B.

A client who received magnesium sulfate during labor.

C.

A client who has a history of oligohydramnios.

D.

A client whose newborn is having difficulty latching-on.

Answer and Explanation

The Correct Answer is B

Choice A rationale

 

A client whose labor lasted for 6 hours is not necessarily a priority unless other complications are present. Duration of labor alone does not indicate an urgent need for immediate attention postpartum.

 

Choice B rationale

 

A client who received magnesium sulfate during labor should be seen first due to the potential for serious side effects such as respiratory depression, hypotonia in the newborn, and maternal complications. Magnesium sulfate is used to prevent seizures in clients with preeclampsia and requires close monitoring.

 

Choice C rationale

 

A client with a history of oligohydramnios needs monitoring, but this condition alone does not take precedence over the immediate postpartum risks associated with magnesium sulfate.

 

Choice D rationale

 

A client whose newborn is having difficulty latching-on needs support and assistance with breastfeeding. While important, this issue is not as urgent as monitoring the effects of magnesium sulfate in the client described in Choice B.


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View Related questions

Correct Answer is A

Explanation

Choice A rationale

This finding indicates fetal distress. Recurrent variable decelerations in the fetal heart rate (FHR) can be a sign of umbilical cord compression, which can compromise fetal oxygenation.

Choice B rationale

Uterine contractions every 6 minutes are within the normal range for the latent phase of labor and do not indicate fetal risk.

Choice C rationale

Moderate variability of the FHR is a reassuring sign and suggests that the fetus is well-oxygenated and neurologically intact.

Choice D rationale

Uterine contractions lasting 30 to 45 seconds are typical for the latent phase of labor and do not indicate fetal distress.

Correct Answer is ["C","E"]

Explanation

Choice A rationale

Douching is generally not recommended, especially during pregnancy, because it can disrupt the natural balance of bacteria in the vagina, potentially leading to infections or other complications.

Choice B rationale

Avoiding urination at bedtime is not advisable, as holding in urine can increase the risk of urinary tract infections (UTIs). Frequent urination is a good practice to help prevent and manage UTIs.

Choice C rationale

Wearing cotton-crotch underwear is recommended because cotton is breathable and helps to keep the genital area dry, reducing the risk of infections and irritation.

Choice D rationale

Eliminating yogurt products from the diet is not necessary; in fact, yogurt contains probiotics that can be beneficial for maintaining a healthy balance of bacteria in the gut and vaginal area.

Choice E rationale

Refraining from taking bubble baths is advised, as the chemicals in bubble bath products can irritate the urethra and increase the risk of UTIs.

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