Level: Clinical
Difficulty: Medium
Subtopic: Postpartum assessment
NCLEX: A postpartum client on the mother-baby unit is being evaluated for immediate postpartum recovery. Assessment data…
Maternal-newborn nursing Health Promotion and Maintenance Reduction of Risk Potential
Case Study
A postpartum client on the mother-baby unit is being evaluated for immediate postpartum recovery. Assessment data include blood pressure 88/54 mm Hg, heart rate 128/min, and saturated perineal pads. Which assessment approach should the nurse use first?
Question
A. Screen for instability, then perform a focused assessment related to the presenting concern.
B. Begin invasive procedures before any focused assessment.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
B. Begin invasive procedures before any focused assessment.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: A. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.