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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Developing a plan of care with the child and family is important, but it does not explicitly address the need for cultural competence. This approach is cantered around collaboration rather than cultural sensitivity.

Choice B reason: Providing future-based care for culturally diverse children is vague and does not directly indicate an understanding or application of cultural competence in the current care situation.

Choice C reason: Treating all children the same regardless of their culture is contrary to the principles of culturally competent care. Culturally competent care involves recognizing and respecting the cultural differences that impact the child's health and tailoring the care to meet those unique needs.

Choice D reason: Assessing the child's culture and providing care based on the findings demonstrates an understanding and application of culturally competent care. This approach ensures that the care is respectful of and responsive to the cultural needs of the child and family.

Correct Answer is ["64"]

Explanation

To calculate the maintenance IV fluid rate for a child, we typically use the Holliday-Segar formula:

For the first 10 kg of weight: 100 ml/kg/day
For the next 10 kg of weight: 50 ml/kg/day
For any additional weight: 20 ml/kg/day

The weight of the child is 48 pounds, which is approximately 21.8 kg (since 1 pound = 0.45 kg).

Using the formula:

First 10 kg: 100 ml/kg/day = 1000 ml/day
Next 10 kg: 50 ml/kg/day = 500 ml/day
Remaining 1.8 kg: 20 ml/kg/day = 36 ml/day

Total = 1000 ml + 500 ml + 36 ml = 1536 ml/day

To find the rate in ml/hr: 1536 ml/day ÷ 24 hours/day = 64 ml/hr

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

The paediatric nurse is teaching the student nurse about culturally competent care. Which action will the student nurse identify as consistent with this type of care?

Correct Answer is D

Explanation

The nurse is calculating maintenance IV fluid requirements for a child who weighs 48 pounds. Using the continuous fluid maintenance formula, calculate the rate (ml/hr) the nurse will set the pump? Round to the nearest whole number. Enter the number only, no units.

Correct Answer is ["64"]

Explanation

The nurse is caring for a G4P1, 31 weeks and 2 days gestation, 41-year-old patient, with premature prolonged rupture of membranes (PPROM) 7 hours after delivery. Which interventions will the nurse include in the plan of care? Select all that apply.

The nurse is performing an initial health history on a newly pregnant patient with "pre-diabetes." How will the nurse respond to this finding?

The nurse is assessing the bottle-feeding technique of a new family. Which behaviour by the parents requires further teaching?

The nurse is caring for an infant delivered one minute ago. The infant has no spontaneous respirations, no response to stimulus, is limp, pale, and has a heart rate of 99 beats per minute. How will the nurse document this infant's APGAR Score? Enter number only (no units).

A pregnant person telephones the prenatal clinic and reports that their "water just broke." How will the nurse respond?

The nurse is caring for a G4P1, 31 weeks and 2 days gestation, 41-year-old patient, with premature prolonged rupture of membranes (PPROM) 7 hours after delivery. Which interventions will the nurse include in the plan of care? Select all that apply.

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

The nurse is caring for a patient experiencing precipitous Labor. What complication will the nurse monitor this patient for?