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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Review the client's serum calcium level. Rationale: Checking the client's serum calcium level is not the most appropriate action in this situation. Hand and finger spasms during blood pressure measurement are more likely due to discomfort or muscle tension than a calcium deficiency. There is no immediate indication that the client's calcium level needs to be assessed urgently.
Choice B rationale:
Administer an as-needed (PRN) antianxiety medication. Rationale: Administering an antianxiety medication is not indicated in this situation. The client's symptoms of hand and finger spasms during blood pressure measurement are not likely related to anxiety. It is essential to address the immediate issue of obtaining an accurate blood pressure reading.
Choice C rationale:
Ask the UAP to take the blood pressure in the other arm. Rationale: This is the correct answer. When the UAP reports spasms in the client's right hand and fingers while taking blood pressure using the same arm, the nurse should prioritize obtaining an accurate blood pressure measurement. Asking the UAP to use the other arm can help ensure a more reliable reading. Muscle spasms in the arm being used for blood pressure measurement can lead to inaccurate results.
Choice D rationale:
Tell the UAP to use a different sphygmomanometer. Rationale: In this scenario, the issue appears to be related to muscle spasms in the client's hand and fingers rather than the sphygmomanometer itself. Changing the sphygmomanometer is unlikely to resolve the problem. The priority is to obtain an accurate blood pressure reading by addressing the spasms in the arm being used.
Correct Answer is B
Explanation
Choice A rationale:
Ask the mother if any visitors were expected to arrive. Rationale: While it is essential to gather information from the mother, such as whether any visitors were expected, this action does not address the immediate concern of a potentially missing newborn. Matching ID bands is a critical first step in ensuring the safety and security of all infants and mothers on the unit.
Choice B rationale:
Match ID bands of all infants and mothers on the unit. Rationale: This is the correct answer. In a situation where a new mother believes her infant is missing, the nurse's priority is to ensure the safety and security of all infants and mothers. Matching ID bands can help confirm the identity of each infant and mother and prevent any potential mix-ups or missing infants.
Choice C rationale:
Determine if the newborn is in the nursery. Rationale: While it is essential to check the nursery to determine if the newborn is there, it should not be the first action taken. Matching ID bands of all infants and mothers is a more immediate and comprehensive approach to ensuring the safety and security of all patients on the unit.
Choice D rationale:
Activate the lockdown procedure. Rationale: Activating the lockdown procedure should only be done in situations where there is a security threat or immediate danger to the safety of patients and staff. In this case, the primary concern is not a security threat but rather the potential misplacement of an infant. Matching ID bands and confirming the whereabouts of all infants and mothers are more appropriate initial actions.
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