The nurse is assisting a patient 2 hours post-vaginal birth out of bed to the bathroom for the first time. Which interventions will the nurse implement? Select all that apply.

Have the patient sit on the side of the bed.

Walk alongside the patient to the bathroom.

Obtain an oral temperature.

Assess for sensation in the lower extremities.

Assess bowel sounds and passing flatus.

Answer and Explanation

Correct Answer : A,B,D

Choice A reason: Having the patient sit on the side of the bed before standing is crucial to prevent dizziness or fainting, especially after giving birth. This intervention allows the patient to stabilize and ensures that they do not experience sudden drops in blood pressure, which can lead to falls.

Choice B reason: Walking alongside the patient to the bathroom is important to provide support and ensure their safety. The patient may still be weak or unsteady after giving birth, and having the nurse nearby can help prevent falls and provide assistance if needed.

Choice C reason: Obtaining an oral temperature is not immediately necessary when assisting a patient to the bathroom post-vaginal birth. While monitoring vital signs is important, this intervention does not directly contribute to the immediate need for safe ambulation.

Choice D reason: Assessing for sensation in the lower extremities is essential to ensure that the patient has regained feeling and control in their legs. This assessment helps to determine if there are any residual effects from epidural anaesthesia or other factors that may affect mobility and safety.

Choice E reason: Assessing bowel sounds and passing flatus is important for overall postpartum care but is not directly related to assisting the patient to the bathroom. This intervention is more relevant to monitoring gastrointestinal recovery and function after childbirth.

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Correct Answer is D

Explanation

Choice A reason: A folic acid deficiency in the mother's diet during pregnancy is typically associated with neural tube defects, such as spina bifida, rather than causing patent ductus arteriosus (PDA).

Choice B reason: PDAs are not specifically more common in male newborns. This statement does not accurately reflect the risk factors associated with PDA.

Choice C reason: The statement about a 25% chance of having another baby with PDA is not accurate. While having one child with a heart defect may slightly increase the risk for subsequent children, the exact risk percentage varies and is not typically as high as 25%.

Choice D reason: A family history of heart defects is a known risk factor for PDA. Genetic predisposition can play a role in the occurrence of congenital heart defects, making this the correct answer.

A. Oral suspension. B. Intravenous infusion. C. Subcutaneous injection. D. Intramuscular injection.

Correct Answer is D

Explanation

Choice A reason: Oral suspension is not an appropriate method for administering botulinum toxin. This medication is not effective when taken orally and needs to be administered directly into the muscle to address spasticity.

Choice B reason: Intravenous infusion is also not the appropriate method for administering botulinum toxin. The medication is intended to act locally at the site of injection to reduce muscle spasticity, and intravenous administration would not achieve the desired localized effect.

Choice C reason: Subcutaneous injection is not the correct method for administering botulinum toxin. This medication needs to be injected directly into the muscle to have a therapeutic effect on muscle spasticity.

Choice D reason: Intramuscular injection is the correct method for administering botulinum toxin. The medication works by blocking the release of acetylcholine at the neuromuscular junction, thereby reducing muscle spasticity. Administering it directly into the muscle ensures that the medication reaches its target and provides the desired therapeutic effect.

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The nurse is assisting a patient 2 hours post-vaginal birth out of bed to the bathroom for the first time. Which interventions will the nurse implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a full-term newborn diagnosed with persistent/patent ductus arteriosus (PDA). The newborn's caregiver asks the nurse, "What causes a PDA?" How will the nurse answer this question?

Correct Answer is D

Explanation

The nurse is preparing to administer botulinum toxin to a child with spastic cerebral palsy. How will the nurse administer this medication?

Correct Answer is D

Explanation

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