A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements indicates to the nurse that further teaching is needed??
"I am likely to have a fever during the first week I am home."
"I will call my provider if I have discharge from my incision."
"I should not have unrelieved pain in my abdomen."
"I will resume taking my prenatal vitamins."
The Correct Answer is A
A. Having a fever during the first week at home is not a normal or expected finding and may indicate an infection, requiring further assessment.
B. Contacting the provider for incisional discharge is a proper response.
C. Not having unrelieved pain in the abdomen is an appropriate expectation.
D. Resuming prenatal vitamins is a normal postoperative recommendation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Acrocyanosis is a normal finding in newborns and does not require immediate intervention.
B. Not passing meconium within the first 24 hours is not uncommon and may be normal.
C. Persistent tachycardia in a newborn, especially with a heart rate of 180 bpm, requires immediate intervention as it may indicate a cardiac or other medical issue.
D. Not voiding within the first 24 hours may be normal, but it should be monitored.
Correct Answer is C
Explanation
A. Changing the perineal pad of a client who has just been transferred from the labor ward is a task that should not be delegated to an assistive personnel (AP) since it is beyond their scope.
B. Monitoring vital signs during the admission of a client with gestational hypertension requires nursing judgment and assessment skills.
C. Providing a sitz bath to a client with a fourth-degree laceration and is 2 days post- partum can be delegated to an AP. This task does not require the nurse's clinical judgment or assessment skills, and it can be safely performed by the AP following the nurse's instructions.
D. Observing an area of redness on the breast requires nursing assessment and intervention.
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