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 D
Explanation
Choice A rationale
The Oucher scale uses photographic images or numerical scales and is appropriate for older children who can visually correlate their pain level with the provided scale. It is not ideal for younger children or those unable to understand numerical or photographic representations.
Choice B rationale
The Visual Analog Scale requires a more mature understanding of concepts such as gradients and is suitable for older children and adults. It is not an appropriate tool for a 5-year-old as their cognitive development may limit the accurate use of this scale.
Choice C rationale
The FLACC scale assesses pain based on behavioral observations and is ideal for non-verbal or very young children. However, a 5-year-old can generally articulate their pain or utilize pictorial representations, making other scales more suitable.
Choice D rationale
The FACES scale, featuring cartoonish faces representing varying pain levels, is a validated tool for children as young as 3 years old. Its simplicity and visual clarity make it an effective and age-appropriate method for a 5-year-old to communicate their pain level.
Correct Answer is A
Explanation
Choice A rationale
Horizontal eustachian tubes in children with cleft palate increase the risk of otitis media due to impaired drainage and ventilation. Surgical closure of the palate helps restore anatomical structure, reducing the incidence of middle ear infections and associated complications.
Choice B rationale
Small external ear structure is not anatomically linked to hydrocephalus, and diuretics are unrelated to managing this condition. Hydrocephalus stems from cerebrospinal fluid accumulation, not external ear anatomy, making this option inaccurate.
Choice C rationale
A large tongue may lead to airway obstruction but is not linked to otitis externa. Ear drops manage external ear infections but do not address anatomical changes associated with cleft palate, which impacts the eustachian tubes and middle ear.
Choice D rationale
An opening in the lip does not directly cause pneumonia. Pneumonia is primarily a respiratory condition influenced by infections, not lip anatomy. Corticosteroids are not standard interventions for pneumonia related to cleft palate complications.
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