The nurse has received change of shift report on the following four clients. Which of the clients should the nurse assess first?

Correct Answer: D

Rationale: In this scenario, the nurse should assess Client D first because she had an asthma attack during the last shift, indicating a potentially life-threatening condition that requires immediate attention. Asthma exacerbations can be dangerous during the postpartum period due to increased oxygen demand and potential complications. Client A has hyperemesis gravidarum and vomiting, which are common during early pregnancy but not immediately life-threatening. Client B is receiving terbutaline for preterm labor but has no complaints of cramping, so there is no urgent need for assessment. Client C, who had a bilateral tubal ligation, may require monitoring for postoperative complications but is not as critical as assessing a client with a recent asthma attack. Educationally, this scenario emphasizes the prioritization of care based on the urgency and acuity of the situation. Understanding the potential risks and complications associated with different conditions in pregnancy and postpartum is crucial for nurses to provide safe and effective care to their patients. Prioritization skills are essential in healthcare settings to ensure that the most critical needs are addressed promptly.

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to perform at this time is to check the client’s lochia flow (Option A). This is the most appropriate response because assessing lochia flow is crucial in the postpartum period to monitor for signs of excessive bleeding, which could indicate postpartum hemorrhage—a common complication after childbirth. Option B, asking the client if she is having chills, is incorrect in this situation as the vital signs provided do not indicate any signs of infection or sepsis, which are typically associated with chills. Option C, encouraging the client to drink fluids, is also not the priority at this time as the client's vital signs are stable and do not suggest dehydration or hypovolemia. Option D, assessing the client’s lung fields, is not necessary based on the information provided. The client's vital signs do not suggest any respiratory distress or lung-related issues. In an educational context, understanding the significance of monitoring vital signs and assessing postpartum clients is essential for nurses working in labor and delivery or postpartum units. This question highlights the importance of recognizing postpartum complications such as postpartum hemorrhage and the role of ongoing assessment in providing quality postpartum care.

Correct Answer: B

Rationale: In the postpartum period, it is crucial for nurses to assess and monitor various aspects of a mother's health, including the risk for fluid volume deficit. The appropriate goal for a postpartum client with a nursing diagnosis of potential for fluid volume deficit is to maintain a normal lochial flow (Option B). Explanation of why Option B is correct: - Lochia is the postpartum vaginal discharge containing blood, mucus, and uterine tissue. Monitoring and ensuring a normal lochial flow is essential in assessing postpartum hemorrhage and fluid status. Any deviation from normal lochial flow could indicate a potential issue with fluid volume balance. Explanation of why other options are incorrect: - Option A (Minimal perineal pain): While important for the mother's comfort, perineal pain is not directly related to fluid volume deficit. - Option C (Normal temperature): Temperature regulation is important but not specifically related to fluid volume deficit. - Option D (Weight reduction): Weight reduction is not a priority in the immediate postpartum period and is not directly related to fluid volume status. Educational context: Understanding nursing diagnoses, setting appropriate goals, and prioritizing interventions based on the client's needs are critical skills for nurses in maternal health. Monitoring and managing fluid volume balance in the postpartum period are vital for preventing complications and promoting recovery. By selecting the correct goal related to fluid volume balance, nurses can provide effective care and support to postpartum clients.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) When gastric aspirate is removed from the tube. This is because the presence of gastric aspirate confirms that the tube is in the stomach, which is the intended location for an orogastric gavage tube. Option B) When the baby suckles on the tubing is incorrect because a baby suckling on the tubing does not provide a reliable indication of proper tube placement. It can be a dangerous assumption to rely on the baby's action to determine tube location. Option C) When respirations are unlabored during tube insertion is incorrect as it does not directly correlate with tube placement. Unlabored respirations indicate the baby's overall respiratory status, not tube location. Option D) When the tubing can be inserted no farther is incorrect because the length of insertion does not guarantee correct placement. It's important to verify the tube location through appropriate means like aspirating gastric contents. In the educational context, it is crucial for nurses to understand the importance of verifying tube placement using evidence-based methods to ensure the safety and well-being of the preterm baby. Proper tube placement is essential to prevent complications such as aspiration and ensure effective delivery of nutrition or medication. Nurses must follow established protocols and guidelines to confirm tube placement accurately.

Correct Answer: A

Rationale: The correct answer is A) Nothing, because this is an acceptable weight loss. In the first few days after birth, it is common for newborns to lose up to 10% of their birth weight. This weight loss is mainly due to the loss of excess fluid and meconium. In the case of this 4-day-old neonate who has lost 286 grams (which is within the expected range), there is no cause for alarm. Option B) Advise the mother to stop breastfeeding and give formula is incorrect because breastfeeding should be continued as it provides numerous health benefits to both the baby and the mother. Formula feeding is not necessary in this situation. Option C) Notify the neonatologist of the excessive weight loss is incorrect because the weight loss described is within the normal range for a newborn. There is no need to escalate the situation to the neonatologist. Option D) Give the baby dextrose water between breast feedings is incorrect because there is no indication to provide dextrose water to a newborn who is breastfeeding and experiencing normal weight loss. Introducing unnecessary supplements can disrupt breastfeeding and may not be beneficial. In an educational context, understanding the normal weight changes in newborns is crucial for healthcare providers working with infants and new mothers. Educating nurses and caregivers about expected weight loss in neonates can help prevent unnecessary interventions and promote successful breastfeeding practices.