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 D
Explanation
Choice A rationale:
The clinical finding of 0 station does not provide information about the fetal head's position in the left occiput posterior position. Station refers to the level of the presenting part in relation to the ischial spines, not the position.
Choice B rationale:
The clinical finding of 0 station does not indicate that the largest fetal diameter has passed through the pelvic outlet. The station only tells us the level of the presenting part and does not provide information about the diameter passing through the pelvic outlet.
Choice C rationale:
The clinical finding of 0 station does not directly involve the palpability of the posterior fontanel. Station is determined based on the level of the presenting part in the birth canal.
Choice D rationale:
This is the correct interpretation of the clinical finding. 0 station means that the presenting part (usually the baby's head) is at the level of the ischial spines, which serves as a reference point during labor. As labor progresses and the baby moves further down the birth canal, the station becomes more negative (e.g., -1, -2) until delivery occurs.
Correct Answer is D
Explanation
Choice A rationale:
Increased pancreatic activity during pregnancy causing fat intolerance is not related to the cause of indigestion and heartburn. Pancreatic activity can change during pregnancy, but it does not directly impact indigestion and heartburn.
Choice B rationale:
Increased estrogen production causing more hydrochloric acid in the stomach is not the cause of indigestion and heartburn during pregnancy. While hormones can influence digestion, the mechanism for indigestion and heartburn lies elsewhere.
Choice C rationale:
Pressure from the growing uterus pushing up on the stomach and intestines is a contributing factor to indigestion and heartburn during pregnancy. However, it is not the primary cause. The main cause is related to the relaxation of the cardiac sphincter.
Choice D rationale:
Progesterone causes relaxation of the cardiac sphincter, which is a muscular valve that prevents stomach acid from flowing back into the esophagus. When this sphincter relaxes, it can lead to acid reflux and subsequent indigestion and heartburn during pregnancy. The nurse should educate the client about this hormonal effect to help manage these symptoms effectively.
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