A nurse is caring for a client who is postpartum and has a perineal laceration. Which of the following findings places the client at risk for delayed wound healing?
The client is changing the perineal pad once daily.
The client is using witch hazel pads on the perineum.
The client cleans the perineum with a squeeze bottle after urinating.
The client's perineal suture line is well-approximated.
The Correct Answer is A
Choice A rationale:
Changing the perineal pad once daily could lead to infection, which would delay wound healing.
Choice B rationale:
Witch hazel pads are often used for their soothing and anti-inflammatory properties, which can aid in healing.
Choice C rationale:
Cleaning the perineum with a squeeze bottle after urinating helps to keep the area clean and promote healing.
Choice D rationale:
A well-approximated suture line indicates that the wound edges are close together, which is conducive to healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
A blood pressure of 88/40 mm Hg is lower than the normal range (90/60 to 120/80 mm Hg) and could indicate hemorrhage.
Choice B rationale:
A urinary output of 40 mL/hr is within the normal range (30 to 60 mL/hr) and does not indicate hemorrhage.
Choice C rationale:
Moderate rubra lochia is normal for a postpartum woman and does not indicate hemorrhage.
Choice D rationale:
A heart rate of 90/min is within the normal range (60 to 100 beats/min) and does not indicate hemorrhage.
Correct Answer is A
Explanation
Choice A rationale:
The client is experiencing postpartum hemorrhage, and the nurse should first collect hemoglobin and hematocrit levels to assess the extent of blood loss.
Choice B rationale:
Inserting an indwelling urinary catheter is not the immediate priority. It may be done later to monitor fluid balance.
Choice C rationale:
Administering oxygen is important, but it’s not the first action. The nurse needs to assess the extent of blood loss first.
Choice D rationale:
Preparing the client to receive a plasma expander is important, but it’s not the first action. The nurse needs to assess the extent of blood loss first.
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