The nurse is assisting a patient 2 hours post-vaginal birth out of bed to the bathroom for the first time. Which interventions will the nurse implement? Select all that apply.

Have the patient sit on the side of the bed.

Walk alongside the patient to the bathroom.

Obtain an oral temperature.

Assess for sensation in the lower extremities.

Assess bowel sounds and passing flatus.

Answer and Explanation

Correct Answer : A,B,D

Choice A reason: Having the patient sit on the side of the bed before standing is crucial to prevent dizziness or fainting, especially after giving birth. This intervention allows the patient to stabilize and ensures that they do not experience sudden drops in blood pressure, which can lead to falls.

Choice B reason: Walking alongside the patient to the bathroom is important to provide support and ensure their safety. The patient may still be weak or unsteady after giving birth, and having the nurse nearby can help prevent falls and provide assistance if needed.

Choice C reason: Obtaining an oral temperature is not immediately necessary when assisting a patient to the bathroom post-vaginal birth. While monitoring vital signs is important, this intervention does not directly contribute to the immediate need for safe ambulation.

Choice D reason: Assessing for sensation in the lower extremities is essential to ensure that the patient has regained feeling and control in their legs. This assessment helps to determine if there are any residual effects from epidural anaesthesia or other factors that may affect mobility and safety.

Choice E reason: Assessing bowel sounds and passing flatus is important for overall postpartum care but is not directly related to assisting the patient to the bathroom. This intervention is more relevant to monitoring gastrointestinal recovery and function after childbirth.

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Correct Answer is B

Explanation

Choice A reason: Requesting an enteral tube is not necessary unless the child is unable to eat orally at all. The goal is to support the child's ability to eat independently, if possible.

Choice B reason: Providing large, padded utensils can help a child with cerebral palsy improve their ability to eat independently. Adaptive utensils are designed to accommodate the motor challenges that children with cerebral palsy may face, making it easier for them to grasp and use the utensils.

Choice C reason: While having the parents feed the child can be a short-term solution, it does not promote independence. The focus should be on finding ways to support the child's ability to eat on their own.

Choice D reason: Referring the patient to a nutritionist can be helpful for overall dietary management, but it does not directly address the immediate issue of the child's difficulty with using regular utensils. Adaptive utensils are a more direct solution to this problem.

A. Increases the return of venous blood back to the heart. B. Is a common position when a child is tachycardic. C. Decreases arterial blood flow away from the heart. D. Increases the workload of the heart.

Correct Answer is A

Explanation

Choice A reason: Squatting increases the return of venous blood back to the heart by compressing the large veins in the legs and abdomen. This position helps increase systemic vascular resistance, which in turn increases the blood flow to the lungs and improves oxygenation. Children with Tetralogy of Fallot often instinctively squat to relieve cyanotic spells, as it helps reduce the severity of symptoms by temporarily improving circulation.

Choice B reason: While a child might experience tachycardia during a cyanotic spell, squatting is not a position specifically associated with tachycardia. The primary purpose of squatting in children with Tetralogy of Fallot is to improve venous return and systemic vascular resistance, not to address tachycardia directly.

Choice C reason: Squatting does not decrease arterial blood flow away from the heart. Instead, it helps increase systemic vascular resistance, which improves pulmonary blood flow and oxygenation. This position assists in temporarily mitigating the effects of the heart defect by improving circulation.

Choice D reason: Squatting actually helps alleviate some of the workload on the heart by improving systemic vascular resistance and enhancing blood flow to the lungs. It is a compensatory mechanism that children with Tetralogy of Fallot use instinctively to manage cyanotic spells, and it does not increase the workload of the heart.

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The nurse is assisting a patient 2 hours post-vaginal birth out of bed to the bathroom for the first time. Which interventions will the nurse implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a 4-year-old with cerebral palsy on an inpatient unit who is struggling to eat with regular utensils. What intervention will the nurse include in the plan of care?

Correct Answer is B

Explanation

The nurse is caring for a child diagnosed with Tetralogy of Fallot who has positioned themselves in a squatting position. The nurse understands this position:

Correct Answer is A

Explanation

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