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
Explanation
A. slight yellow vaginal discharge: Gonorrhea often presents with a purulent or yellowish vaginal discharge in females. It is one of the common symptoms along with pelvic pain and dysuria.
B. Decrease in urinary frequency: Gonorrhea can actually increase urinary frequency or cause dysuria. A decrease in frequency is not typical for gonorrhea.
C. frothy, white vaginal discharge: This is more characteristic of Trichomoniasis, not gonorrhea. Gonorrhea usually presents with a thicker, more purulent discharge.
D. low grade fever for three (3) days: While fever can be associated with many infections, it is not a common primary symptom of gonorrhea in the absence of more specific symptoms like discharge or pelvic pain.
Correct Answer is B
Explanation
A. Sunken fontanels: Sunken fontanels are typically associated with dehydration rather than abusive head trauma.
B. Retinal haemorrhage: Retinal haemorrhages are a key indicator of abusive head trauma, such as shaken baby syndrome. They are caused by the shearing forces of rapid acceleration and deceleration.
C. Laceration to forearm: While concerning, a laceration to the forearm is not specific to abusive head trauma and could result from various types of trauma.
D. Large bruises on the body: While large bruises might indicate physical abuse, they are not specific to head trauma and do not point as directly to abusive head trauma as retinal haemorrhages do.
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