When caring for a postpartum client, the nurse notes that the client's perineal pad is saturated with bright red blood.
What is the priority to ask the client?

When was the last time you changed your pad?

Have you passed any clots?

Are you having any cramping?

Do you have to go to the bathroom? .

Answer and Explanation

The Correct Answer is A

Choice A rationale

Determining the time of the last pad change assesses the rate of bleeding, which is crucial for evaluating postpartum hemorrhage. Bright red blood saturation indicates active bleeding, requiring quantification. If pads are saturated within an hour, immediate intervention is needed to prevent hypovolemic shock.

Choice B rationale

Asking about clots identifies uterine atony or retained placental fragments. However, it does not prioritize the bleeding rate assessment, which is critical for immediate hemodynamic stability and guides urgency in management.

Choice C rationale

Cramping indicates uterine contractions aiding involution. While helpful for understanding uterine activity, it does not directly evaluate the severity or rate of blood loss, which poses an immediate risk to the client’s life.

Choice D rationale

Checking for the need to urinate helps assess bladder distension. A full bladder inhibits uterine contraction, worsening atony-related bleeding. Still, this line of questioning is less critical compared to assessing the bleeding's rate and volume.

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Correct Answer is C

Explanation

Choice A rationale

A history of pelvic inflammatory disease may result in complications like infertility or chronic pelvic pain but does not specifically indicate endometriosis. Endometriosis involves the ectopic implantation of endometrial tissue, unrelated to infection from PID.

Choice B rationale

An atypical Papanicolaou smear suggests cervical cell abnormalities due to infection, inflammation, or dysplasia, but it does not correlate with endometriosis, which is a distinct gynecological condition involving ectopic endometrial tissue growth.

Choice C rationale

Dysmenorrhea unresponsive to NSAIDs is a defining symptom of endometriosis. This pain results from the inflammatory response and cyclic bleeding of ectopic endometrial tissue, which can cause significant discomfort and impair quality of life.

Choice D rationale

Abdominal bloating several days before menses may be linked to hormonal fluctuations or gastrointestinal issues but is not a primary symptom of endometriosis. While some affected individuals experience bloating, it is not a diagnostic feature like severe, treatment-resistant pain. .

A. Accurately measure intake and output. B. Provide for several periods of uninterrupted rest. C. Maintain a thermoneutral environment. D. Encourage periods of bonding. E. Use an incentive spirometer 10 times every hour.

Correct Answer is ["C"]

Explanation

Choice A rationale

Assessing the baseline fetal heart rate (FHR) over a 10-minute period ensures accurate measurement by capturing rate fluctuations due to fetal activity or maternal factors. This duration is a standardized method to establish a representative baseline. Variability is excluded during this time, focusing on a stable resting rate.

Choice B rationale

Baseline FHR can be obtained using ultrasound or auscultation, both being reliable non-invasive methods for assessing fetal well-being. These tools accurately detect cardiac activity and provide real-time data, allowing consistent monitoring during labor.

Choice C rationale

Baseline FHR cannot be obtained during contractions due to transient accelerations or decelerations caused by uterine compression. These changes do not represent the resting heart rate. Accurate baseline assessments require a period without uterine activity to avoid skewed results.

Choice D rationale

A normal FHR of 110-160 bpm indicates adequate oxygenation and neural regulation. This range reflects the fetal cardiovascular system's ability to adapt to in utero conditions. Values outside this range might suggest hypoxia, infection, or other abnormalities.

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When caring for a postpartum client, the nurse notes that the client's perineal pad is saturated with bright red blood.What is the priority to ask the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is ["C"]

Explanation

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When caring for a postpartum client, the nurse notes that the client's perineal pad is saturated with bright red blood.
What is the priority to ask the client?