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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Thrombocytopenia is deﬁned as a platelet count of less than 150,000/microL1.

Severe neonatal thrombocytopenia (platelet count <50,000/microL) can be associated with bleeding and potentially signiﬁcant morbidity.

As a result, it is important to identify at-risk neonates and report low platelet counts to the provider.

Choice B is incorrect because a hematocrit of 48% is within the normal range for a newborn.

Choice C is incorrect because a blood glucose level of 58 mg/dl is within the normal range for a newborn.

Choice D is incorrect because a hemoglobin level of 16 g/dL is within the normal range for a newborn.

A. "Eat a high-fat snack before getting out of bed.” B. "Avoid eating snacks before bedtime.” C. "Consume foods served at cool temperatures.” D. "Drink additional liquids with each meal.”

Correct Answer is C

Explanation

A nurse should recommend that a client who is experiencing nausea and vomiting during pregnancy consume foods served at cool temperatures. This is because cool foods may be easier to tolerate than hot foods.

Choice A is not correct because high-fat foods can worsen nausea and vomiting during pregnancy.

Choice B is not correct because eating a snack before bedtime may help prevent nausea and vomiting in the morning.

Choice D is not correct because drinking additional liquids with meals can worsen nausea and vomiting during pregnancy.

Instead, it may be helpful to sip ﬂuids throughout the day.

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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?

Nursing Test Bank

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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