A nurse is caring for a client who is 1 hr postpartum.

Exhibits

For each assessment finding, click to specify if the finding indicates the client's condition has improved or remains unchanged. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Blood pressure

Skin temperature

Fundal assessment

Bleeding

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"}}

Blood pressure: At 2100, the client’s BP was 90/56 mm Hg, indicating hypotension likely from postpartum hemorrhage. By 2115, BP increased to 108/72 mm Hg, showing improved hemodynamic stability after interventions such as fundal massage, oxytocin administration, and bladder emptying.
Skin temperature: At both 2100 and 2115, the client’s skin remained cool to the touch. This could indicate ongoing peripheral vasoconstriction or residual hypoperfusion, suggesting that although circulation improved, thermoregulation and peripheral perfusion have not fully normalized.
Fundal assessment: Initially, the fundus was boggy, deviated to the right, and 2 cm above the umbilicus, indicating uterine atony worsened by bladder distention. After catheterization and uterotonic therapy, the fundus became midline, firm, and at the level of the umbilicus, which is expected postpartum and reduces bleeding risk.
Bleeding: At 2100, there was heavy lochia rubra saturating a perineal pad in 20 min with passage of a large clot. At 2115, bleeding decreased to a moderate amount of lochia rubra with a few pea-sized clots, indicating that hemorrhage control measures were effective.

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Correct Answer is B

Explanation

Rationale:

A. "I will use an interpreter when providing client teaching.": An interpreter is useful for clients with language barriers. Expressive aphasia affects speech production, not comprehension, so an interpreter would not address the main communication challenge.

B. "I will use a communication board to assess the client's needs.": A communication board allows the client to point to words, pictures, or symbols to express thoughts and needs without relying on verbal speech. This is an effective method for facilitating communication with expressive aphasia.

C. "I will provide written instructions for the client in 8-point font.": Written instructions can help if reading skills are intact, but 8-point font is too small for easy readability, especially for clients who may also have vision changes. Larger, clear print is recommended.

D. "I will use indirect lighting in the client's room.": Lighting preferences may improve comfort, but they do not address the core communication difficulty caused by expressive aphasia. This intervention is unrelated to improving the client-nurse communication.

A. Personalize the conflict. B. Identify solutions prior to negotiation. C. Attempt to understand both sides of the issue. D. Focus on how the conflict occurred.

Correct Answer is C

Explanation

A. Personalize the conflict: Making a conflict personal can increase tension and defensiveness among staff. Effective negotiation requires addressing issues objectively rather than targeting individuals.

B. Identify solutions prior to negotiation: Preselecting solutions may limit collaborative problem-solving. Effective negotiation involves exploring options with all parties to reach mutually acceptable outcomes.

C. Attempt to understand both sides of the issue: Understanding each party’s perspective promotes open communication, trust, and collaboration. This approach helps identify common ground and develop solutions that are acceptable to all involved.

D. Focus on how the conflict occurred: Concentrating on past events can create blame and hinder forward-focused problem-solving. Effective negotiation emphasizes current needs and potential solutions rather than dwelling on the cause.

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A nurse is caring for a client who is 1 hr postpartum. Exhibits For each assessment finding, click to specify if the finding indicates the client's condition has improved or remains unchanged. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse and a newly licensed nurse are discussing effective communication techniques for a client who has expressive aphasia. Which of the following statements by the newly licensed nurse indicate understanding of the teaching?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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A nurse is caring for a client who is 1 hr postpartum.

Exhibits

For each assessment finding, click to specify if the finding indicates the client's condition has improved or remains unchanged. There must be at least 1 selection in every row. There does not need to be a selection in every column.