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 A
Explanation
A. The priority is to assess the client's uterine fundus to determine if it is well-contracted. Excessive bleeding could be indicative of uterine atony, and prompt assessment is crucial for intervention.
B. Assisting the client on a bedpan to urinate is a secondary intervention. While a distended bladder can contribute to uterine atony, assessing the fundus comes first to determine the cause.
C. Increasing fluid intake is important for postpartum recovery, but it is not the immediate priority in this situation.
D. Preparing to administer oxytocic medication may be necessary if uterine atony is identified during the fundal assessment. However, assessing the fundus comes first to guide appropriate interventions.
Correct Answer is C
Explanation
A. Placing the baby on the stomach is not recommended due to the risk of sudden infant death syndrome (SIDS).
B. Placing the crib next to the heater may cause overheating, which is a risk factor for SIDS.
C. Removing extra blankets from the baby's crib is important to reduce the risk of SIDS.
D. Padding the mattress in the baby's crib is not recommended as it can pose a suffocation risk.
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