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 ["A","C","D"]

Explanation

Choice A reason: Lethargy and hypotonia are critical findings in a child who was left in a closed car. These symptoms can indicate severe dehydration, heat stroke, or other serious conditions that require immediate medical attention.

Choice B reason: Elastic skin turgor generally indicates good hydration status and is not an immediate concern that needs to be reported urgently in this context.

Choice C reason: An apical heart rate of 64 beats per minute is significantly low for a 14-month-old child, indicating bradycardia, which can be a sign of severe heat stress or dehydration. This finding needs immediate reporting.

Choice D reason: A blood pressure of 100/54 mmHg is within the normal range for many paediatric patients, but in the context of being left in a hot car, it can suggest potential complications and should be monitored closely. However, it is not as critical as the heart rate and mental status findings.

Choice E reason: A flat anterior fontanel is a normal finding in infants and does not require urgent intervention in this context.

A. My baby has a higher risk of developing jaundice. B. This procedure was required because my baby was breech. C. The vacuum was required because I did not dilate past 6 centimetres. D. My baby’s head will be cone-shaped for about 2 months.

Correct Answer is A

Explanation

Choice A reason: This statement indicates the parent's understanding that vacuum-assisted deliveries can sometimes lead to an increased risk of jaundice. The use of a vacuum can cause bruising on the baby's scalp, which can lead to the breakdown of red blood cells, thereby increasing bilirubin levels. Elevated bilirubin levels can cause jaundice in newborns. Recognizing this potential risk and monitoring the baby for signs of jaundice is an essential aspect of post-delivery care.

Choice B reason: Stating that the procedure was required because the baby was breech is incorrect. Vacuum-assisted delivery is typically used in cases where the baby is in a cephalic (head-first) position and there are difficulties in progressing through the birth canal, such as when the mother is exhausted, or the baby needs to be delivered quickly due to fatal distress. Breech presentations often necessitate a caesarean section instead of a vacuum-assisted delivery.

Choice C reason: The assertion that the vacuum was required because the mother did not dilate past 6 centimetres is inaccurate. Vacuum-assisted delivery is not related to cervical dilation but rather to difficulties encountered during the second stage of Labor (pushing phase). The decision to use a vacuum is made when the baby is in the birth canal, and additional assistance is needed to facilitate delivery.

Choice D reason: Stating that the baby’s head will be cone-shaped for about 2 months is also incorrect. While a vacuum-assisted delivery can result in a temporary cone-shaped head (known as "caput succedaneum" or melding), this typically resolves within a few days to weeks after birth. It is not expected to last for two months. Proper education should clarify the temporary nature of the head shape changes.

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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.

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Naxlex Comprehensive Predictor Exams

The emergency department nurse is assessing a 14-month-old child who was left inside a closed car for an hour. The outside temperature was 88 degrees Fahrenheit. Which assessment findings will the nurse report immediately to the health care provider? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

The nurse is teaching a parent who delivered the baby with vacuum-assisted delivery. Which of the following statements will confirm to the nurse that the teaching was effective?

Correct Answer is A

Explanation

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