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 to ask the client?
When was the last time you changed your pad?
Have you passed any clots?
Are you having any cramping?
Do you have to go to the bathroom? .
The Correct Answer is A
Choice A rationale
Determining the time of the last pad change assesses the rate of bleeding, which is crucial for evaluating postpartum hemorrhage. Bright red blood saturation indicates active bleeding, requiring quantification. If pads are saturated within an hour, immediate intervention is needed to prevent hypovolemic shock.
Choice B rationale
Asking about clots identifies uterine atony or retained placental fragments. However, it does not prioritize the bleeding rate assessment, which is critical for immediate hemodynamic stability and guides urgency in management.
Choice C rationale
Cramping indicates uterine contractions aiding involution. While helpful for understanding uterine activity, it does not directly evaluate the severity or rate of blood loss, which poses an immediate risk to the client’s life.
Choice D rationale
Checking for the need to urinate helps assess bladder distension. A full bladder inhibits uterine contraction, worsening atony-related bleeding. Still, this line of questioning is less critical compared to assessing the bleeding's rate and volume.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Weight gain is a common side effect of corticosteroids, which alter metabolism and promote fluid retention. This effect can be pronounced in patients with muscular dystrophy, as corticosteroids are used to slow disease progression but may lead to unwanted changes in body composition.
Choice B rationale
Mood changes are another potential side effect of corticosteroids. These medications can affect neurotransmitter regulation in the brain, resulting in mood swings, irritability, or even more serious psychiatric effects such as depression or anxiety.
Choice C rationale
Chronic fatigue is not a primary side effect of corticosteroids. While muscular dystrophy itself may cause fatigue due to muscle wasting and decreased activity, the corticosteroids typically do not directly contribute to this symptom.
Choice D rationale
Osteoporosis is a long-term side effect of corticosteroid use, as these medications can interfere with calcium absorption and bone metabolism. Prolonged use may weaken bones, increasing the risk of fractures, especially in growing adolescents.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
A slurping or clicking sound indicates poor latching and is often associated with air entering the mouth due to improper seal or positioning of the infant. These sounds can reflect nipple misalignment or inadequate breast tissue placement into the infant's mouth, affecting milk transfer and leading to potential breastfeeding complications, such as nipple pain or reduced milk intake.
Choice B rationale
Audible swallowing confirms that the infant is successfully transferring milk and is properly latched. Proper latch allows efficient milk removal, which triggers swallowing reflexes. It reflects an absence of air entry and indicates that the infant is receiving milk without difficulty, promoting both nutritional intake and breastfeeding success.
Choice C rationale
The infant's tongue cupping under the breast with lips flanged ensures proper latch by creating a vacuum seal. This position prevents air leakage and allows effective milk transfer. Tongue cupping and lip flanging optimize compression of the lactiferous sinuses, supporting effective breastfeeding and minimizing discomfort for the mother.
Choice D rationale
Rhythmic sucking is a sign of coordinated latch and feeding. It reflects successful milk transfer and synchronization between suckling and swallowing. Rhythmic patterns reduce the risk of nipple trauma by ensuring proper placement and suction. This indicates that breastfeeding dynamics are efficient and beneficial.
Choice E rationale
Dimpling of the infant's cheeks occurs due to suction difficulties and often signifies improper latch or weak oral musculature. It leads to air leakage and insufficient milk removal. This finding may contribute to feeding inefficiencies and nipple trauma, indicating a need for latch correction.
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