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?

Answer and Explanation

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.

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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.

A. Provide education on oral contraceptives B. Removal of intrauterine device prior to treatment C. Institute contact precautions D. Administer acyclovir as ordered

Correct Answer is B

Explanation

A. Provide education on oral contraceptives. This is not a priority for treating acute PID, though education on preventing sexually transmitted infections (STIs) that can lead to PID is important.
B. Removal of intrauterine device prior to treatment. This is a priority intervention because an intrauterine device (IUD) can be a source of infection and inflammation, exacerbating pelvic inflammatory disease (PID). Removing it can help reduce infection risk and facilitate treatment.
C. Institute contact precautions. PID is typically not spread by casual contact, so standard precautions are sufficient.
D. Administer acyclovir as ordered. Acyclovir is used to treat viral infections like herpes and is not relevant for bacterial infections like PID, which is usually treated with antibiotics.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is B

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