Difficulty: Medium
Average Score: 76%
Simulated
Passage / Scenario
Four clients, each two hours post-birthAfter 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?
Correct answer
A
Rationale
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. A multigravida whose peri-pad is 1/4 saturated with lochia rubra after one hour is normal, strong afterbirth pains during breastfeeding are expected in multiparous women, and a small clot is typical without excessive bleeding.