After completing post anesthesia recovery assessments, the registered nurse (RN) asks the practical nurse (PN) to transfer four clients, each two hours post-birth, to the postpartum unit. Which client should the PN ask the RN to reassess prior to transfer?

A primigravida whose perineal pain has worsened one hour after being medicated.

A multigravida whose peri-pad is 1/4 saturated with lochia rubra after one hour.

A multigravida complaining of strong afterbirth pains when breastfeeding.

A primigravida who passed a small clot when she sat up on the edge of the bed

Answer and Explanation

The Correct Answer is A

This client should be reassessed by the RN prior to transfer, as worsening perineal pain may indicate a hematoma, infection, or inadequate pain management. The RN should inspect the perineum, check the vital signs, and evaluate the eﬀectiveness of the medication.

The other options are not correct because:

B .A multigravida whose peri-pad is 1/4 saturated with lochia rubra after one hour does not need to be reassessed by the RN, as this is a normal finding for a client two hours post-birth. Lochia rubra is the red-colored vaginal discharge that contains blood and debris from the placental site, and it usually lasts for 3 to 4 days after delivery. A peri-pad that is 1/4 saturated after one hour is within the expected range of blood loss.

C. A multigravida complaining of strong afterbirth pains when breastfeeding does not need to be reassessed by the RN, as this is a normal finding for a client two hours post-birth. Afterbirth pains are cramps caused by uterine contractions that help shrink the uterus and prevent bleeding. They are more common and intense in multiparous women and during breastfeeding, as oxytocin is released and stimulates the contractions.

D. A primigravida who passed a small clot when she sat up on the edge of the bed does not need to be reassessed by the RN, as this is a normal finding for a client two hours post-birth. Small clots may form in the uterus or vagina due to pooling of blood during rest or anesthesia, and they are usually expelled when changing position or ambulating. As long as the clot is smaller than a plum and there is no excessive bleeding or pain, it is not a cause for concern.

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Correct Answer is C

Explanation

A nurse caring for a client who is at 36 weeks of gestation and has methicillin- resistant Staphylococcus aureus (MRSA) should initiate Contact Precautions.

Choice A is incorrect because Droplet Precautions are not necessary for MRSA.
Choice B is incorrect because a Protective Environment is not necessary for MRSA.
Choice D is incorrect because Airborne Precautions are not necessary for MRSA.

A. Baked chicken. B. French fries. C. Whole milk. D. Bacon cheeseburger.

Correct Answer is A

Explanation

Baked chicken is a food that the nurse should recommend for a client who is at

32 weeks of gestation and has cholelithiasis to include in her diet.

Eating healthy fats, like those found in lean meats such as chicken, can help the gallbladder contract and empty on a regular basis.

Choice B is incorrect because French fries are not a food that the nurse should recommend for a client who is at 32 weeks of gestation and has cholelithiasis to include in her diet.

Unhealthy fats, like those often found in fried foods, should be avoided.

Choice C is incorrect because whole milk is not a food that the nurse should recommend for a client who is at 32 weeks of gestation and has cholelithiasis to include in her diet.

Unhealthy fats, like those often found in whole milk, should be avoided.

Choice D is incorrect because a bacon cheeseburger is not a food that the nurse should recommend for a client who is at 32 weeks of gestation and has cholelithiasis to include in her diet.

Unhealthy fats, like those often found in bacon and cheeseburgers, should be avoided.

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After completing post anesthesia recovery assessments, the registered nurse (RN) asks the practical nurse (PN) to transfer four clients, each two hours post-birth, to the postpartum unit. Which client should the PN ask the RN to reassess prior to transfer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 36 weeks of gestation and has methicillin- resistant Staphylococcus aureus. Which of the following types of isolation precautions should the nurse initiate?

Correct Answer is C

Explanation

A nurse is providing dietary teaching to a client who is at 32 weeks of gestation and has cholelithiasis. Which of the following foods should the nurse recommend for the client to include in her diet?

Correct Answer is A

Explanation

A nurse is providing nutritional guidance to a client who is pregnant and follows a vegan diet. The client asks the nurse which foods she should eat to ensure adequate calcium intake. The nurse should instruct the client that which of the following foods has the highest amount of calcium?

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