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 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.
Correct Answer is B
Explanation
Choice A rationale
A heart rate of 89/min is within the normal range for an adult, and would not typically be a cause for concern.
Choice B rationale
Cool, clammy skin can be a sign of shock or other serious conditions such as hypoperfusion or inadequate blood flow, which could be a sign of hemorrhage or other circulatory issues. This is a significant finding that should be reported to the provider immediately. Hypoperfusion can lead to inadequate oxygen supply to the body’s organs and tissues, which can result in organ failure and other serious complications. Therefore, any signs of hypoperfusion, including cool, clammy skin, should be reported to the provider immediately for further evaluation and treatment.
Choice C rationale
A blood pressure of 120/70 mm Hg is within the normal range for an adult, and would not typically be a cause for concern.
Choice D rationale
Moderate lochia serosa is a normal finding in a woman who is 3 days postpartum. Lochia serosa is the term for the pink or brownish discharge that occurs after lochia rubra, the bright red discharge that occurs immediately after childbirth. Lochia serosa typically begins about 3- 4 days after delivery and can continue for up to 10 days postpartum.
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