When caring for a postpartum client the nurse notes that the client's perineal pad is saturated with bright red blood. What is the priority question to ask the client?
Have you passed any clots?
Do you have to go to the bathroom?
When was the last time you changed your pad?
Are you having any cramping?
The Correct Answer is A
A. Have you passed any clots? This is important to assess for potential postpartum hemorrhage, which can be indicated by passage of large clots.
B. Do you have to go to the bathroom? This does not directly address the issue of excessive bleeding.
C. When was the last time you changed your pad? This provides information about the amount of bleeding but does not address clotting.
D. Are you having any cramping? Cramping is common postpartum but does not directly assess for hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Sole creases on heels. Sole creases are a sign of maturity and are usually present in full-term infants, not preterm.
B. Ruddy skin color. This is more common in infants with polycythemia or those who are small for gestational age, not specifically linked to prematurity.
C. Flexion of all four extremities. Premature infants typically have less muscle tone and may exhibit less flexion, often appearing more limp or having extended extremities.
D. Scant amount of vernix caseosa. Premature infants typically have more vernix caseosa, which protects their delicate skin in utero. The amount decreases closer to full term, but at 31 weeks, there may still be a moderate amount.
Correct Answer is ["A","C","E"]
Explanation
A. Rhythmic suckling. Indicates the infant is effectively extracting milk.
B. A slurping sound as the infant sucks. This suggests poor latch and possible ingestion of air.
C. Tongue down with lips flanged. Shows that the infant's tongue is extended over the lower gum and lips are flared outward, creating a seal.
D. Dimpling of the infant's cheeks while sucking. Indicates improper latch and poor seal around the breast.
E. Audible swallowing. Indicates milk transfer is occurring as the infant swallows.
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