A nurse is caring for a client who is 1 day postpartum and is taking a sitz bath. To determine the client's tolerance of the procedure, which of the following assessments should the nurse perform?
Bladder distention.
Pulse rate.
Respiratory rate.
Color of lochia.
The Correct Answer is B
Choice A rationale:
Assessing for bladder distention is important for postpartum clients, especially those who have undergone perineal trauma during childbirth. However, it is not the priority assessment during a sitz bath. The sitz bath is usually done to promote healing and comfort, and monitoring pulse rate takes precedence to identify any adverse reactions.
Choice B rationale:
Pulse rate should be the priority assessment during a sitz bath for a postpartum client. Sitz baths can cause vasodilation, leading to a potential drop in blood pressure, increased heart rate, or dizziness. Monitoring the pulse rate helps identify any cardiovascular changes or adverse reactions.
Choice C rationale:
Respiratory rate is not the priority assessment during a sitz bath. It is essential to monitor, but it is less likely to be affected directly by the sitz bath compared to the pulse rate and cardiovascular changes.
Choice D rationale:
Monitoring the color of lochia is essential for assessing postpartum bleeding and uterine healing. However, during a sitz bath, the priority assessment should be focused on cardiovascular changes and any adverse reactions the client might experience.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Tamoxifen is not used to treat Non-Hodgkin's lymphoma. Tamoxifen is a selective estrogen
receptor modulator (SERM) and is primarily used in breast cancer treatment. It functions by
binding to estrogen receptors, blocking estrogen's effects, and inhibiting the growth of
hormone-sensitive breast cancer cells.
Choice B rationale:
Tamoxifen is not used to treat endometriosis. Endometriosis is a condition in which tissue
similar to the lining of the uterus grows outside the uterus, and it is typically managed with
hormonal therapies, pain medications, or surgical interventions, but not tamoxifen.
Choice C rationale:
This is the correct choice. Tamoxifen is widely used in the treatment of breast cancer,
especially in cases of estrogen receptor-positive breast cancer. It helps prevent cancer
recurrence and is often prescribed for both early-stage and advanced breast cancer patients.
Choice D rationale:
Tamoxifen is not used to treat polycystic ovary syndrome (PCOS). PCOS is a hormonal
disorder characterized by enlarged ovaries with small cysts, and it is typically managed with
lifestyle changes, hormonal contraceptives, and medications to regulate menstrual cycles and
manage symptoms like hirsutism and acne.
Correct Answer is B
Explanation
Choice A rationale:
Hypotonicity, or decreased muscle tone, is not an expected finding in a newborn experiencing opioid withdrawals. Opioid withdrawal symptoms usually involve increased muscle tone and jitteriness.
Choice B rationale:
Moderate tremors of the extremities are an expected finding in a newborn experiencing opioid withdrawals. Neonates born to mothers who used opioids during pregnancy can exhibit tremors, irritability, and other withdrawal symptoms.
Choice C rationale:
An axillary temperature of 36.1°C (96.9°F) is within the normal range for a newborn's body temperature, so it is not directly related to opioid withdrawal and is not the expected finding in this situation.
Choice D rationale:
Excessive sleeping is not an expected finding in a newborn experiencing opioid withdrawals. Opioid withdrawal can lead to increased wakefulness and irritability in newborns.
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