A nurse is assessing for pain for a client following a cesarean birth 24 hr ago. Which of the following questions should the nurse ask to determine if a PRN pain medication is indicated?
"Have you noticed any swelling in your feet?"
"Do you have any leakage from your incision?"
"Do you notice increased cramping with breastfeeding?"
"Are you able to pass gas?"
The Correct Answer is C
Explanation
Choice A Reason:
"Have you noticed any swelling in your feet?" This question is inappropriate. Swelling in the feet is not directly related to postoperative pain following a cesarean birth. While swelling may indicate other issues such as fluid retention, it is not typically a primary indicator of pain requiring PRN pain medication.
Choice B Reason:
"Do you have any leakage from your incision?" This question is inappropriate. Leakage from the incision may indicate wound complications such as infection or dehiscence, but it does not specifically assess pain. PRN pain medication would be indicated based on the client's reported pain level, rather than the presence of incisional leakage alone.
Choice C Reason:
"Do you notice increased cramping with breastfeeding?" This question is appropriate. After a cesarean birth, it is common for women to experience cramping, especially during breastfeeding. This is due to the release of oxytocin, a hormone that helps the uterus contract back to its pre-pregnancy size. Increased cramping with breastfeeding can exacerbate postoperative pain in women who have undergone a cesarean birth. Therefore, asking about increased cramping with breastfeeding is an important question to assess pain and determine if additional pain medication is needed.
Choice D Reason:
"Are you able to pass gas?" This question is inappropriate. Passing gas is an important aspect of gastrointestinal function but is not directly related to postoperative pain following a cesarean birth. While constipation and gastrointestinal issues can contribute to discomfort, asking about the ability to pass gas does not specifically assess pain or indicate the need for PRN pain medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Explanation
Choice A Reason:
A client who had a previous stillbirth. While a previous stillbirth may indicate a higher risk pregnancy and the need for close monitoring, it is not a contraindication for a contraction stress test. In fact, a CST may be indicated in this scenario to assess fetal well-being and determine the need for intervention.
Choice B Reason:
A client who has a previous classical incision. A contraction stress test (CST), also known as an oxytocin challenge test, is a prenatal test used to evaluate the response of the fetal heart rate to uterine contractions. It is typically performed in cases where there are concerns about fetal well-being, such as decreased fetal movement or suspected fetal compromise.
Choice C Reason:
A client who has gestational diabetes mellitus. Gestational diabetes mellitus (GDM) is a condition that may necessitate additional fetal surveillance, but it is not a contraindication for a contraction stress test. In fact, clients with GDM may undergo fetal testing such as CSTs to monitor fetal well-being, particularly if there are concerns about placental function or fetal growth.
Choice D Reason:
A client who had a nonreactive nonstress test. A nonreactive nonstress test (NST) indicates that the fetal heart rate did not increase adequately in response to fetal movement during the test. While this may raise concerns about fetal well-being and prompt further evaluation, it is not a contraindication for a contraction stress test. Instead, a CST may be performed as a follow-up test to assess the fetal heart rate response to uterine contractions.
Correct Answer is B
Explanation
Explanation
Choice A Reason:
Vulva lesions are not typically associated with trichomoniasis. Trichomoniasis primarily affects the vagina and cervix rather than the vulva.
Choice B Reason:
Malodorous discharge is a common symptom of trichomoniasis. The discharge may have a strong, unpleasant odor.
Choice C Reason:
Urinary frequency is not a typical symptom of trichomoniasis. However, some individuals may experience mild urinary symptoms such as burning or discomfort during urination.
Choice D Reason:
Thick, white vaginal discharge is more indicative of a yeast infection (such as candidiasis) rather than trichomoniasis. Trichomoniasis typically presents with a frothy, yellow-green, or gray vaginal discharge.
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