When assessing the A of the acronym REEDA, the nurse should evaluate the

Correct Answer: C

Rationale: In pediatric respiratory assessment, the acronym REEDA stands for Redness, Edema, Ecchymosis, Discharge, and Approximation. When assessing the "A" in REEDA, which stands for Approximation, the nurse should evaluate the edges of the episiotomy. This is the correct answer because in the context of pediatric respiratory assessment, the focus is on wound healing and evaluating the integrity of the surgical incision site. Option A, skin color, is incorrect as it does not directly relate to the assessment of an episiotomy in pediatric respiratory care. Option B, degree of edema, is also incorrect as it focuses on swelling, which is not specifically related to the evaluation of an episiotomy site. Option D, assessing the episiotomy for discharge, is incorrect as it pertains to wound drainage rather than the specific evaluation of the incision edges. Educationally, understanding the components of REEDA is crucial for pediatric nurses to accurately assess wound healing and identify any signs of complications following procedures like episiotomies. By evaluating the edges of the episiotomy, nurses can ensure proper healing and early detection of any issues, promoting optimal patient outcomes.

Correct Answer: D

Rationale: The correct answer is D because support stockings should be applied before the patient rises from bed in the morning to prevent venous congestion. Choices A, B, and C are incorrect as they do not address the prevention of thrombus formation. It is essential to educate the patient on proper measures to prevent thrombus formation, especially after childbirth when the risk is increased.

Correct Answer: D

Rationale: A temperature elevation of greater than 38°C (100.4°F) on two postpartum days, not including the first 24 hours, signifies infection. 37.5°C (99.6°F) in the first 48 hours is expected due to dehydration. To be classified as an infection, the temperature needs to be greater than 38°C (100.4°F). An elevated temperature is anticipated in the first 24 hours after delivery, so it is not a definitive indicator of infection.

Correct Answer: B

Rationale: The correct answer is B because in the early stages of hypovolemic shock, clinical signs include normal blood pressure, decreased pulse pressure, compensatory tachycardia, and pale, cool skin color. These signs indicate the body's compensatory response to the decreased blood volume. Other options such as a decrease in heart rate or flushed skin are not consistent with the diagnosis of hypovolemic shock.

Correct Answer: C

Rationale: Lacerations of the birth canal should always be suspected if excessive bleeding continues when the fundus is firm. Bleeding from the genital tract often is bright red, in contrast to the darker red color of lochia. A firm fundus, pulse of 90 bpm, blood pressure of 110/78 mm Hg, and being medicated twice in one shift are common findings in the postpartum patient.