RN Nursing · Normal Postpartum Care · Practice question
A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?
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Change the initial perineal pad of a client who just transferred from labor and delivery.
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✓
Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum.
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Monitor vital signs during admission of a client who has gestational hypertension.
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Observe an area of redness on the breast of a client who is 1 day postpartum.
Answer & explanation
Correct: Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum.
Delegation to assistive personnel must follow the principles of appropriate scope of practice: APs can perform tasks that are routine, repetitive, and do not require nursing assessment, clinical judgment, or teaching. Providing a sitz bath to a stable postpartum client who is 2 days postpartum with a fourth-degree laceration is a routine comfort and hygiene measure that does not require assessment or judgment; the AP can safely carry out this task under the nurse's supervision. Changing the initial perineal pad of a client who just transferred from labor and delivery is not appropriate to delegate because the nurse must assess the amount and character of lochia and the perineal condition at first assessment — this requires clinical judgment. Monitoring vital signs during admission of a gestational hypertension client involves assessment and interpretation of findings, which is a nursing responsibility. Observing redness on a breast is an assessment task requiring the nurse to determine whether it represents mastitis, engorgement, or another condition, and to initiate appropriate interventions. Because the sitz bath task is procedural and non-assessment in nature, it is the only appropriate delegation choice from this list.
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