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A nurse on an obstetrics-gynecology unit is planning care for four clients after receiving change of shift report. Which of the following clients should the nurse assess first?

A.

A client who is 4 days postpartum and has mastitis

B.

A client who had a bilateral tubal ligation 12 hr previously

C.

A client admitted 1 hr ago for an ectopic pregnancy

D.

A client who is a 1 day postpartum after a late term miscarriage

Answer and Explanation

The Correct Answer is C

Rationale:

 

A. A client who is 4 days postpartum and has mastitis should be assessed, but this condition is less acute compared to the others.

 

B. A client who had a bilateral tubal ligation 12 hr previously requires post-operative monitoring, but this is less urgent than the client with an ectopic pregnancy.

 

C. A client admitted 1 hr ago for an ectopic pregnancy is the priority as this condition can be life-threatening and requires immediate assessment.

 

D. A client who is 1 day postpartum after a late-term miscarriage requires care, but the immediacy is less than that of the ectopic pregnancy client.


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View Related questions

Correct Answer is D

Explanation

Rationale:

A. WBC 6,000/mm³ is within normal range and does not require follow-up.

B. BUN 15 mg/dL is within normal range and does not require follow-up.

C. Hemoglobin 14 g/dL is within normal range for most adults and does not require follow-up.

D. Platelet count 60,000/mm³ is significantly low and requires follow-up as it can increase the risk of bleeding during surgery.

Correct Answer is C

Explanation

Rationale:

A. Opening a sterile tray flap toward the body can be incorrect practice, but it is a minor procedural issue that does not necessarily pose an immediate risk.

B. Using clean gloves is appropriate for non-sterile tasks like discontinuing an IV infusion.

C. Using a telephone number as identification is not acceptable; proper identification should include at least two identifiers like name and date of birth.

D. Emptying a colostomy pouch when it is one-third full is appropriate practice to prevent overflow and maintain hygiene.

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