A nurse is caring for a client who had a vaginal birth 2 hr ago and has soaked two perineal pads in the past 30 min. Which of the following actions should the nurse take?

Assist the client to a sitz bath.

Assess the client's uterine tone.

Encourage the client to breastfeed.

Apply an ice pack to the client's perineum.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Assisting the client to a sitz bath is not the priority action in this situation. The client has soaked two perineal pads in the past 30 minutes, indicating excessive bleeding, which requires immediate attention.

Choice B rationale:

Assessing the client's uterine tone is essential to determine if the uterus is contracting appropriately. Uterine atony, where the uterus fails to contract after childbirth, is a common cause of postpartum hemorrhage. Assessing the tone helps identify this issue and allows for timely interventions.

Choice C rationale:

Encouraging the client to breastfeed may have benefits such as promoting uterine contractions through oxytocin release. However, the priority in this scenario is addressing the potential postpartum hemorrhage.

Choice D rationale:

Applying an ice pack to the client's perineum may provide comfort, but it does not address the concerning symptom of excessive bleeding and potential postpartum hemorrhage.

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Correct Answer is A

Explanation

Choice A rationale:

Naegele's Rule is used to estimate the expected delivery date (EDD) by adding 7 days and 9 months to the first day of the last menstrual period (LMP) In this case, May 4th, 2018, is the first day of the LMP. Adding 7 days brings us to May 11th, and then adding 9 months brings us to February 11th, 2019, which is the estimated delivery date.

Choice B rationale:

This option is incorrect because it adds 9 months to the LMP without accounting for the additional 7 days, resulting in an inaccurate EDD.

Choice C rationale:

This option is incorrect because it only adds 9 months to the LMP without considering the 7 days, leading to an inaccurate EDD.

Choice D rationale:

This option is incorrect because it adds 9 months to the LMP without considering the 7 days, resulting in an inaccurate EDD.

A. Hypertonia. B. Jitteriness. C. Acrocyanosis. D. Generalized petechiae.

Correct Answer is B

Explanation

Choice A rationale:

Hypertonia (increased muscle tone) is not a manifestation of hypoglycemia in a newborn. Instead, hypotonia (decreased muscle tone) is more characteristic.

Choice B rationale:

This is the correct choice. Jitteriness is a common sign of hypoglycemia in a newborn. It may be accompanied by other symptoms like poor feeding, tremors, and irritability.

Choice C rationale:

Acrocyanosis (bluish discoloration of the hands and feet) is a normal finding in newborns and is not specifically associated with hypoglycemia.

Choice D rationale:

Generalized petechiae (small red or purple spots on the skin caused by bleeding under the skin) are not indicative of hypoglycemia but may be associated with other medical conditions.

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A nurse is caring for a client who had a vaginal birth 2 hr ago and has soaked two perineal pads in the past 30 min. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A pregnant client's last menstrual period was May 4th, 2018. What is this client's estimated delivery date using Naegele's Rule?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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