After completing post anesthesia recovery assessments, the registered nurse (RN) asks the practical nurse (PN) to transfer four clients, each two hours post-birth, to the postpartum unit. Which client should the PN ask the RN to reassess prior to transfer?
A primigravida whose perineal pain has worsened one hour after being medicated.
A multigravida whose peri-pad is 1/4 saturated with lochia rubra after one hour.
A multigravida complaining of strong afterbirth pains when breastfeeding.
A primigravida who passed a small clot when she sat up on the edge of the bed
The Correct Answer is A
This client should be reassessed by the RN prior to transfer, as worsening perineal pain may indicate a hematoma, infection, or inadequate pain management. The RN should inspect the perineum, check the vital signs, and evaluate the effectiveness of the medication.
The other options are not correct because:
B .A multigravida whose peri-pad is 1/4 saturated with lochia rubra after one hour does not need to be reassessed by the RN, as this is a normal finding for a client two hours post-birth. Lochia rubra is the red-colored vaginal discharge that contains blood and debris from the placental site, and it usually lasts for 3 to 4 days after delivery. A peri-pad that is 1/4 saturated after one hour is within the expected range of blood loss.
C. A multigravida complaining of strong afterbirth pains when breastfeeding does not need to be reassessed by the RN, as this is a normal finding for a client two hours post-birth. Afterbirth pains are cramps caused by uterine contractions that help shrink the uterus and prevent bleeding. They are more common and intense in multiparous women and during breastfeeding, as oxytocin is released and stimulates the contractions.
D. A primigravida who passed a small clot when she sat up on the edge of the bed does not need to be reassessed by the RN, as this is a normal finding for a client two hours post-birth. Small clots may form in the uterus or vagina due to pooling of blood during rest or anesthesia, and they are usually expelled when changing position or ambulating. As long as the clot is smaller than a plum and there is no excessive bleeding or pain, it is not a cause for concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
If a prolapsed cord is identified, the nurse should perform a vaginal examination and ensure the presenting part is pushed upwards to relieve pressure on the cord.
Choice A) is not correct because while it is important to cover the cord with a sterile saline saturated towel if it has prolapsed externally 1, it is not the next action after calling for assistance and notifying the provider.
Choice C) is not correct because administering oxygen via non-rebreather mask at 8 L/min is not mentioned as an immediate intervention for a prolapsed cord .
Choice D) is not correct because initiating an infusion of IV fluids for the client is not mentioned as an immediate intervention for a prolapsed cord .
Correct Answer is A
Explanation
A bedside glucometer reading of 65 mg/dL is within the normal range for a newborn who is 6 hours old.
Feeding the newborn can help maintain their blood glucose level.
Choice B is not an answer because administering 50 mL of dextrose solution IV is not necessary for a newborn with a normal blood glucose level.
Choice C is not an answer because reassessing the blood glucose level prior to the next feeding is not necessary for a newborn with a normal blood glucose level.
Choice D is not an answer because obtaining a blood sample for a serum glucose
level is not necessary for a newborn with a normal blood glucose level.
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