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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Breast milk typically comes in 3 to 5 days postpartum.
B. This timeline is too early for the onset of mature breast milk.
C. This timeline is too late for the onset of mature breast milk.
D. This timeline is too late for the onset of mature breast milk.

A. Place 3 to 4 pillows under the client's knees when resting in bed. B. Massage the client's posterior lower legs. C. Have the client ambulate. D. Apply warm, moist heat to the client's lower extremities.

Correct Answer is C

Explanation

A. Placing pillows under the client's knees may provide comfort but does not address the prevention of thromboembolic disease.
B. Massaging the client's posterior lower legs may increase the risk of dislodging a clot in clients with a history of thromboembolic disease.
C. Having the client ambulate helps prevent venous stasis and reduces the risk of thromboembolic events.
D. Applying warm, moist heat to the client's lower extremities may provide comfort but does not address the prevention of thromboembolic disease.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is planning care for a client who is 2 hours postpartum following a cesarean birth. The client has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care?

Correct Answer is C

Explanation

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