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 C
Explanation
Yellow exudate will form at the surgical site in 24 hours.
After a Plastibell circumcision, the penis might develop a yellow-ish discharge which is a normal side effect that should go away in a few days.
Choice A is incorrect because the foreskin may darken around the ring while it remains on the penis until it falls off naturally in 7-10 days.
Choice B is incorrect because the plastic ring remains on the penis until foreskin falls off naturally in 7-10 days.
Choice D is incorrect because there is no information found that suggests making sure the newborn’s diaper is snug after a Plastibell circumcision.
Correct Answer is D
Explanation
A third-degree perineal laceration is a tear that extends through the vaginal tissue, perineal skin, and perineal muscles and involves the anal sphincter.
This type of laceration requires careful repair and management to prevent complications such as infection, fecal incontinence, and pain.
Choice A is incorrect because abdominal distention is not a contraindication to the use of a suppository.
Choice B is incorrect because afterpains are common postpartum uterine contractions and are not a contraindication to the use of a suppository.
Choice C is incorrect because vaginal candidiasis is a fungal infection and is not a contraindication to the use of a suppository.
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