Question

A nurse is assessing a client for pain following a cesarean birth 24 hours ago. Which should the nurse ask to determine if a PRN pain medication is needed?

Answer 1

Correct Answers:

Do you notice increased cramping with breastfeeding?

Rationale :

🔹 Increased cramping with breastfeeding often indicates uterine contractions (afterpains), which can cause pain requiring medication.

🔹 Swelling in feet and leakage from incision are important assessments but not directly related to pain management.

🔹 Asking about the ability to pass gas assesses bowel function but does not indicate pain levels.

🔹 This question directly targets the source of postpartum pain.

🔹 Proper pain assessment improves comfort and recovery.

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Answer 2

Correct Answers:

Check the client’s serum medication level.

Rationale :

🟢 Checking serum digoxin levels provides an objective measure of medication adherence and therapeutic effectiveness.

🟢 Apical pulse assessment is important for safety but does not confirm adherence.

🟢 Asking the client relies on self-report, which may be inaccurate.

🟢 Kidney function impacts digoxin excretion but is indirect.

🟢 Lab values guide dosage adjustments and adherence evaluation.

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Answer 3

Correct Answers:

Breast tenderness

Rationale :

🟡 Breast tenderness is a common adverse effect of clomiphene citrate due to hormonal changes.

🟡 Chills, tinnitus, and urinary frequency are not typical side effects.

🟡 Educating clients about expected side effects aids compliance.

🟡 Recognizing side effects prevents unnecessary concern.

🟡 Proper teaching supports effective infertility treatment.

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Answer 4

Correct Answers:

Has your back labor improved?

Rationale :

🟠 The hands-and-knee position aims to relieve back labor, especially with occipitoposterior fetal position.

🟠 Asking if the back pain has improved directly evaluates intervention effectiveness.

🟠 Changes in contraction timing or suprapubic pain are less relevant.

🟠 Assessing pain relief guides ongoing labor management.

🟠 Client feedback is vital for comfort and progress.

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Answer 5

Correct Answers:

Turn the client to a side-lying position.

Rationale :

🔵 Turning the client to a side-lying position improves venous return, helping to counteract hypotension caused by epidural anesthesia.

🔵 Oxygen administration supports oxygenation but does not treat hypotension.

🔵 Massaging the fundus and emptying the bladder are important but secondary interventions.

🔵 Positioning is the most immediate and effective action to stabilize blood pressure.

🔵 Prompt intervention reduces risks of maternal and fetal hypoxia.

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Answer 6

Correct Answers:

Document the guardian’s refusal of the medication.

Rationale :

🟡 When a guardian refuses a prescribed medication like erythromycin ophthalmic ointment, the nurse’s priority is to document the refusal accurately.

🟡 Informing the guardian that the medication can be given after discharge is inappropriate as the medication is typically administered immediately to prevent infection.

🟡 Reporting to social services or ethics committees is reserved for cases of neglect or harm, not simple refusal.

🟡 Proper documentation ensures legal and ethical compliance and facilitates communication with the healthcare team.

🟡 Nurses should also provide education to the guardian about the medication’s importance.

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Answer 7

Correct Answers:

Ibuprofen

Rationale :

🟢 Ibuprofen is a preferred analgesic postpartum due to its effectiveness in pain relief and anti-inflammatory properties with minimal side effects.

🟢 Aspirin is generally avoided postpartum due to bleeding risk.

🟢 Meperidine and fentanyl citrate are opioids and reserved for more severe pain or specific indications.

🟢 NSAIDs like ibuprofen are commonly used for routine postpartum pain management.

🟢 Proper analgesic choice promotes comfort and safety.

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Answer 8

Correct Answers:

Administer 500 mL lactated Ringers IV bolus.

Rationale :

🔵 A steady trickle of vaginal bleeding unresponsive to fundal massage suggests ongoing bleeding and possible hypovolemia.

🔵 Administering a fluid bolus helps maintain circulatory volume and prevents shock.

🔵 Evaluating urinary output is important but follows initial volume resuscitation.

🔵 Ice packs and dressing changes do not control internal bleeding.

🔵 Prompt fluid replacement stabilizes maternal status.

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Answer 9

Correct Answers:

Give your baby an immersion bath daily.

Rationale :

🟠 Offering a pacifier during naps has been shown to reduce the risk of Sudden Infant Death Syndrome (SIDS).

🟠 Triple antibiotic ointment is not recommended for routine umbilical cord care.

🟠 Immersion baths should be avoided until the cord stump falls off.

🟠 Swaddling should allow for flexed hip position, not legs extended, to prevent hip dysplasia.

🟠 Educating parents on safe newborn care promotes health and safety.

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Answer 10

Correct Answers:

Provide the client with a cool sitz bath.

Rationale :

🟣 A cool sitz bath helps reduce perineal swelling and discomfort in clients with a fourth-degree laceration.

🟣 Methylergonovine is used to control uterine bleeding, not perineal pain.

🟣 Warm compresses may increase blood flow and worsen swelling early postpartum.

🟣 Povidone-iodine is not routinely applied to the perineum and may delay healing.

🟣 Appropriate comfort measures aid healing and client satisfaction.

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QLexNursing

1 :
A nurse is assessing a client for pain following a cesarean birth 24 hours ago. Which should the nurse ask to determine if a PRN pain medication is needed?

2 :
A nurse is reviewing the prescriptions for a pregnant client who is taking digoxin. Which action should the nurse take to best evaluate the client's medication adherence?

3 :
A nurse is teaching a client who is experiencing infertility about clomiphene citrate. Which adverse effects should the nurse include?

4 :
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client in a hands-and-knee position. Which should the nurse ask to evaluate the effectiveness of this intervention?

5 :
A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which action should the nurse take?

6 :
A nurse is caring for a newborn immediately following birth who has a prescription for erythromycin ophthalmic ointment.The guardian refuses the medication. Which action should the nurse take?

7 :
A nurse is caring for a client who is postpartum following a vaginal birth. Which analgesic medication should the nurse plan to administer and document in the clients medical record?

8 :
A nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which action should the nurse take?

9 :
A nurse is providing discharge teaching to a postpartum client about caring for their newborn at home. Which of the following statements should the nurse make?

10 :
A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?

QLexNursing

1 : A nurse is assessing a client for pain following a cesarean birth 24 hours ago. Which should the nurse ask to determine if a PRN pain medication is needed?

2 : A nurse is reviewing the prescriptions for a pregnant client who is taking digoxin. Which action should the nurse take to best evaluate the client's medication adherence?

3 : A nurse is teaching a client who is experiencing infertility about clomiphene citrate. Which adverse effects should the nurse include?

4 : A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client in a hands-and-knee position. Which should the nurse ask to evaluate the effectiveness of this intervention?

5 : A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which action should the nurse take?

6 : A nurse is caring for a newborn immediately following birth who has a prescription for erythromycin ophthalmic ointment.The guardian refuses the medication. Which action should the nurse take?

7 : A nurse is caring for a client who is postpartum following a vaginal birth. Which analgesic medication should the nurse plan to administer and document in the clients medical record?

8 : A nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which action should the nurse take?

9 : A nurse is providing discharge teaching to a postpartum client about caring for their newborn at home. Which of the following statements should the nurse make?

10 : A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?

1 :
A nurse is assessing a client for pain following a cesarean birth 24 hours ago. Which should the nurse ask to determine if a PRN pain medication is needed?

2 :
A nurse is reviewing the prescriptions for a pregnant client who is taking digoxin. Which action should the nurse take to best evaluate the client's medication adherence?

3 :
A nurse is teaching a client who is experiencing infertility about clomiphene citrate. Which adverse effects should the nurse include?

4 :
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client in a hands-and-knee position. Which should the nurse ask to evaluate the effectiveness of this intervention?

5 :
A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which action should the nurse take?

6 :
A nurse is caring for a newborn immediately following birth who has a prescription for erythromycin ophthalmic ointment.The guardian refuses the medication. Which action should the nurse take?

7 :
A nurse is caring for a client who is postpartum following a vaginal birth. Which analgesic medication should the nurse plan to administer and document in the clients medical record?

8 :
A nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which action should the nurse take?

9 :
A nurse is providing discharge teaching to a postpartum client about caring for their newborn at home. Which of the following statements should the nurse make?

10 :
A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?