A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?
Change the perineal pad of a client who just transferred from labor and delivery.
Monitor vital signs during admission of a client who has gestational hypertension.
Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum.
Observe an area of redness on the breast of a client who is 1 day postpartum.
The Correct Answer is C
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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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 A
Explanation
A. Vitamin K is a fat-soluble vitamin that is essential for blood clotting. Newborns have low levels of vitamin K because they do not have the intestinal bacteria that produce it. Therefore, they are given an injection of vitamin K shortly after birth to prevent bleeding disorders.
B. Vitamin K is not crucial for the breakdown of bilirubin.
C. Vitamin K primarily plays a role in blood clotting, not the production of white blood cells.
D. Vitamin K is not directly involved in the production of red blood cells.
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