After completing post anesthesia recovery assessments, the registered nurse (RN) asks the practical nurse (PN) to transfer four clients, each two hours post-birth, to the postpartum unit. Which client should the PN ask the RN to reassess prior to transfer?
A primigravida whose perineal pain has worsened one hour after being medicated.
A multigravida whose peri-pad is 1/4 saturated with lochia rubra after one hour.
A multigravida complaining of strong afterbirth pains when breastfeeding.
A primigravida who passed a small clot when she sat up on the edge of the bed.
The Correct Answer is A
This client should be reassessed by the RN prior to transfer, as worsening perineal pain may indicate a hematoma, infection, or inadequate pain management. The RN should inspect the perineum, check the vital signs, and evaluate the effectiveness of the medication.
The other options are not correct because:
B. A multigravida whose peri-pad is 1/4 saturated with lochia rubra after one hour does not need to be reassessed by the RN, as this is a normal finding for a client two hours post-birth. Lochia rubra is a red-colored vaginal discharge that contains blood and debris from the placental site, and it usually lasts for 3 to 4 days after delivery. A peri-pad that is 1/4 saturated after one hour is within the expected range of blood loss.
C. A multigravida complaining of strong afterbirth pains when breastfeeding does not need to be reassessed by the RN, as this is a normal finding for a client two hours post-birth. Afterbirth pains are cramps caused by uterine contractions that help shrink the uterus and prevent bleeding. They are more common and intense in multiparous women and during breastfeeding, as oxytocin is released and stimulates contractions.
D. A primigravida who passed a small clot when she sat up on the edge of the bed does not need to be reassessed by the RN, as this is a normal finding for a client two hours post-birth. Small clots may form in the uterus or vagina due to pooling of blood during rest or anesthesia, and they are usually expelled when changing position or ambulating. As long as the clot is smaller than a plum and there is no excessive bleeding or pain, it is not a cause for concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect- Liver enzymes are important for assessing liver function, but they are not the primary concern when a client with chronic kidney disease is feeling increasingly tired. Epoetin alfa injections are used to stimulate red blood cell production, so the nurse should review a laboratory value related to anemia.
B) Correct- Epoetin alfa is a medication that stimulates the production of red blood cells and is often used to treat anemia associated with chronic kidney disease. A complete blood count (CBC) would provide information about red blood cell levels, hemoglobin, and hematocrit, which are essential for assessing the effectiveness of the treatment.
C) Incorrect- Serum electrolytes are important for assessing overall kidney function and electrolyte balance, but the primary concern here is the client's increasing fatigue. Reviewing a value related to anemia and red blood cell production would be more appropriate.
D) Incorrect- Platelet count is important for assessing blood clotting function, but it's not directly related to the client's increasing fatigue. Anemia-related laboratory values should be the focus.
Correct Answer is A
Explanation
This finding requires immediate action, as it indicates that the client is not receiving the prescribed amount of oxygen, which can compromise the oxygenation and perfusion of the tissues. The PN should adjust the flowmeter to deliver 3 liters per minute of oxygen, and check for any leaks or kinks in the tubing.
The other options are not correct because:
B. The absence of a humidifier does not require immediate action, as it is not a critical component of the oxygen delivery system. A humidifier can help moisten the dry oxygen and prevent mucosal irritation, but it is not essential for oxygenation.
C. The supine position does not require immediate action, as it is not a contraindication for oxygen therapy. The client may prefer this position for comfort or rest, and it does not affect the oxygen delivery or uptake.
D. The snug fit of the cannula does not require immediate action, as it is not a problem for oxygen therapy. The cannula should fit snugly against the client's cheeks to prevent dislodgment or slippage, and it does not interfere with the oxygen flow or diffusion.
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