A certified nursing assistant (CN
Do perineal care for a client who just transferred from labor and delivery.
Monitor an area of redness on the incision of a Cesarean section client who is 1 day postpartum.
Provide discharge instructions on using a sitz bath to a client who is going home.
Monitor signs of pre-eclampsia in a client who has gestational hypertension.
The Correct Answer is A
Choice A rationale
Perineal care for a client who just transferred from labor and delivery is within the scope of practice for a certified nursing assistant (CNA). CNAs are trained to provide basic care, such as hygiene and assistance with activities of daily living, to postpartum clients.
Choice B rationale
Monitoring an area of redness on the incision of a Cesarean section client requires clinical assessment skills beyond the scope of a CNA. It involves evaluating the incision for signs of infection or other complications, which is the responsibility of a registered nurse.
Choice C rationale
Providing discharge instructions, such as using a sitz bath, requires teaching and evaluation skills. Registered nurses are responsible for providing education and ensuring client understanding before discharge.
Choice D rationale
Monitoring for signs of pre-eclampsia involves assessment and interpretation of symptoms such as blood pressure, edema, and proteinuria, which are beyond the scope of a CNA. This is a responsibility of a registered nurse.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Platelets at 140,000 mg are within the normal range and are not typically indicative of postpartum complications like a thrombus.
Choice B rationale
Hemoglobin at 7 mg/dl indicates anemia but is not directly related to the symptoms of pain and tenderness in the calf.
Choice C rationale
A WBC count of 15,000 could indicate an infection or inflammatory process but is not specific to deep vein thrombosis (DVT).
Choice D rationale
Fibrinogen at 600 mg/dl is elevated and can be a marker for increased coagulation activity, which is associated with an increased risk of thrombosis. .
Correct Answer is C
Explanation
Choice A rationale
While it is important to monitor glucose levels, a reading of 40 mg/dL is low and requires immediate attention. Waiting 4 hours could allow the newborn's condition to deteriorate further. Hypoglycemia in newborns can lead to serious complications if not treated promptly.
Choice B rationale
Assessing for hypothermia is essential, but it is not the first priority when a newborn has low blood glucose levels. Immediate steps should be taken to address the hypoglycemia to prevent further complications, as it is a more immediate threat to the newborn's health.
Choice C rationale
Notifying the physician on call is the correct priority intervention. A blood glucose level of 40 mg/dL is concerning, and prompt medical intervention is necessary. The physician can order appropriate treatment to stabilize the newborn's glucose levels and prevent potential complications.
Choice D rationale
Re-evaluating the blood serum glucose is important but comes after initiating immediate intervention. Continuous monitoring should follow initial treatment to ensure the newborn's glucose levels stabilize. Immediate action is crucial to address the hypoglycemia effectively.
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