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 ["A","C","E"]
Explanation
A. I'll expect the plastic ring to fall off by itself within a week. This is correct; the Plastibell ring typically falls off within 5-8 days.
B. I'll apply petroleum jelly to his penis with diaper changes. Incorrect for Plastibell, because the plastic ring itself protects the site, and petroleum jelly can interfere with healing.
C. I'll make sure his diaper is loose in the front. This helps avoid pressure and irritation on the circumcised area.
D. I'll wash his penis with warm water and mild soap each day. Incorrect; the area should be kept clean but only water should be used to avoid irritation.
E. I'll call the doctor if I see any bleeding. Any significant bleeding should be reported to the healthcare provider immediately.
Correct Answer is B
Explanation
A. The baseline FHR can be obtained via ultrasound or auscultation: True. The baseline fetal heart rate can be assessed using ultrasound or auscultation, which are standard methods.
B. The baseline FHR can be obtained during contractions: False. The baseline fetal heart rate should be obtained in the absence of uterine contractions because contractions can temporarily alter the heart rate, making it difficult to determine the true baseline.
C. The baseline FHR is normal between 110-160 bpm: True. This is the accepted normal range for baseline fetal heart rates.
D. The baseline FHR is assessed over a 10-minute period: True. The baseline is typically assessed over a 10-minute window to account for variability and provide an accurate average.
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