A nurse is caring for a client who is 1 day postpartum and is taking a sitz bath. To determine the client's tolerance of the procedure, which of the following assessments should the nurse perform?
Bladder distention.
Pulse rate.
Respiratory rate.
Color of lochia.
The Correct Answer is B
Choice A rationale:
Assessing for bladder distention is important for postpartum clients, especially those who have undergone perineal trauma during childbirth. However, it is not the priority assessment during a sitz bath. The sitz bath is usually done to promote healing and comfort, and monitoring pulse rate takes precedence to identify any adverse reactions.
Choice B rationale:
Pulse rate should be the priority assessment during a sitz bath for a postpartum client. Sitz baths can cause vasodilation, leading to a potential drop in blood pressure, increased heart rate, or dizziness. Monitoring the pulse rate helps identify any cardiovascular changes or adverse reactions.
Choice C rationale:
Respiratory rate is not the priority assessment during a sitz bath. It is essential to monitor, but it is less likely to be affected directly by the sitz bath compared to the pulse rate and cardiovascular changes.
Choice D rationale:
Monitoring the color of lochia is essential for assessing postpartum bleeding and uterine healing. However, during a sitz bath, the priority assessment should be focused on cardiovascular changes and any adverse reactions the client might experience.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Hypertonia (increased muscle tone) is not a manifestation of hypoglycemia in a newborn. Instead, hypotonia (decreased muscle tone) is more characteristic.
Choice B rationale:
This is the correct choice. Jitteriness is a common sign of hypoglycemia in a newborn. It may be accompanied by other symptoms like poor feeding, tremors, and irritability.
Choice C rationale:
Acrocyanosis (bluish discoloration of the hands and feet) is a normal finding in newborns and is not specifically associated with hypoglycemia.
Choice D rationale:
Generalized petechiae (small red or purple spots on the skin caused by bleeding under the skin) are not indicative of hypoglycemia but may be associated with other medical conditions.
Correct Answer is C
Explanation
Choice A rationale:
Digoxin is a cardiac glycoside and is primarily used in the management of certain heart conditions, such as heart failure and atrial fibrillation. It is not indicated for hyperemesis gravidarum, which is severe and persistent vomiting during pregnancy.
Choice B rationale:
Calcium gluconate is a mineral supplement used to treat calcium deficiencies. It is not a standard treatment for hyperemesis gravidarum.
Choice C rationale:
Vitamin Bs (B6 and B12) are commonly used to manage hyperemesis gravidarum. Vitamin B6, also known as pyridoxine, has been shown to alleviate nausea and vomiting during pregnancy. Vitamin B12 may also be administered to help manage symptoms. Both vitamins are safe to use during pregnancy.
Choice D rationale:
Propranolol is a beta-blocker used to treat high blood pressure, heart conditions, and migraines. It is not recommended for managing hyperemesis gravidarum and is generally avoided during pregnancy due to potential risks to the developing fetus.
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