A nurse is assessing a client for pain following a cesarean birth 24 hours ago. Which should the nurse ask to determine if a PRN pain medication is needed?
Have you noticed any swelling in your feet?
Do you notice increased cramping with breastfeeding?
Do you have any leakage from your incision?
Are you able to pass gas?
The Correct Answer is B
The correct answer is choice b. Do you notice increased cramping with breastfeeding?
Choice A rationale: Swelling in the feet is not directly related to the need for PRN pain medication following a cesarean birth. Swelling can be a common postpartum symptom due to fluid retention and changes in blood chemistry, but it does not specifically indicate pain that requires medication.
Choice B rationale: Increased cramping with breastfeeding is a common occurrence due to the release of oxytocin, which causes uterine contractions. This can be quite painful and may necessitate PRN pain medication to manage the discomfort.
Choice C rationale: Leakage from the incision could indicate a complication such as infection or wound dehiscence. While this is a serious concern that requires medical attention, it is not directly related to the typical pain management needs following a cesarean birth.
Choice D rationale: The ability to pass gas is an important indicator of the return of bowel function after surgery, but it is not directly related to the need for PRN pain medication. It is more relevant to assessing gastrointestinal recovery rather than pain levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Providing the newborn with 15 mL glucose water after each feeding is not a recommended action for a newborn undergoing phototherapy for jaundice. While maintaining adequate hydration is important, feedings should consist of breast milk or formula, unless otherwise directed by a healthcare provider.
Choice B rationale
Before starting phototherapy, it’s important to protect the newborn’s eyes from the light by applying eye patches. This can help prevent potential damage to the retinas.
Choice C rationale
Applying hydrating lotion to the newborn’s skin prior to treatment is not a recommended action for a newborn undergoing phototherapy for jaundice. The light needs to be able to penetrate the skin in order to break down the bilirubin, and applying lotion could potentially interfere with this process.
Choice D rationale
Turning the newborn every hour is not a recommended action for a newborn undergoing phototherapy for jaundice. While it’s important to change the newborn’s position regularly to ensure that all areas of the skin are exposed to the light, this does not need to be done on an hourly basis.
Correct Answer is C
Explanation
The first action the nurse should take when caring for a client who has bladder distention following a vaginal birth is to assist the client to the bathroom. Bladder distention can occur after birth due to the pressure on the bladder during labour and birth.
Encouraging the client to empty her bladder will relieve the distention and promote comfort.
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