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:
This statement indicates that the client understands the potential side effects of oral contraception and the importance of reporting them promptly to their healthcare provider. Chest pain, shortness of breath, or leg pain can be indicative of serious complications, such as blood clots, which can occur with oral contraceptive use.
Choice B rationale:
This statement demonstrates the client's understanding of what to do if they miss three pills. Using an alternative form of birth control is a responsible action to prevent unintended pregnancies, as missing multiple pills can decrease contraceptive effectiveness.
Choice C rationale:
This statement reveals a misunderstanding of the appropriate action to take if the client misses three pills. Instead of doubling up, the client should be instructed to take the missed pill as soon as they remember and continue taking the pills as usual. Doubling up can increase the risk of side effects and won't necessarily prevent pregnancy.
Choice D rationale:
This statement indicates that the client comprehends the need for follow-up appointments while on oral contraception. Regular follow-ups are essential to monitor the client's health, address any concerns, and ensure the effectiveness of the chosen contraceptive method.
Correct Answer is C
Explanation
Choice A rationale:
Polyuria is not an adverse effect of epidural anesthesia. It is unrelated to this type of pain control.
Choice B rationale:
Hypertension is not an adverse effect of epidural anesthesia. Epidurals can actually cause a decrease in blood pressure due to vasodilation.
Choice C rationale:
This is the correct choice. Pruritus, or itching, is a common adverse effect of epidural anesthesia caused by the release of histamines from local anesthetics.
Choice D rationale:
Dry mouth is not an adverse effect of epidural anesthesia. Dry mouth is more commonly associated with general anesthesia or medications with anticholinergic effects.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.