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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Webbing typically refers to the presence of extra skin between body parts and is not associated with uneven skinfolds on the buttocks or a clunk during the Ortolani maneuver.
B. Clubfoot refers to a deformity of the foot and is not associated with uneven skinfolds on the buttocks or hip abnormalities.
C. Uneven skinfolds on the buttocks and a clunk during the Ortolani maneuver are indicative of hip dysplasia in a newborn.
D. Polydactyly refers to the presence of extra fingers or toes and is unrelated to the described findings.
Correct Answer is ["A","D","E"]
Explanation
A. Hepatitis B immunization is typically administered soon after birth for protection.
B. Hib immunization is usually given later and not immediately after birth.
C. Lidocaine gel is not routinely used on the umbilical stump.
D. Vitamin K injection is commonly given to prevent bleeding disorders in newborns.
E. Antibiotic ointment to both eyes prevents eye infections that can be caused by bacteria transmitted from the mother during delivery.
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