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 action is appropriate within the RN scope of practice?
Question
A. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
B. Independently diagnose the medical disease and prescribe treatment.
C. Prescribe new medications without a provider order.
D. Delegate nursing assessment and evaluation on an unstable client.
B. Independently diagnose the medical disease and prescribe treatment.
C. Prescribe new medications without a provider order.
D. Delegate nursing assessment and evaluation on an unstable client.
Rationale
Correct answer: A. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
Rationale: RNs assess, coordinate care, teach, and evaluate. Diagnosis and prescribing are provider responsibilities.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: RNs assess, coordinate care, teach, and evaluate. Diagnosis and prescribing are provider responsibilities.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.