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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale:
Demonstrating proper bathing of the infant is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice B rationale:
Verbalizing appropriate car seat safety is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice C rationale:
Identifying individual family member roles is incorrect. This is a goal for the taking-hold phase, not the taking-in phase.
Choice D rationale:
Having adequate nutritional intake is correct. During the taking-in phase, the mother is focused on her own needs, including nutrition.

A. Blood pressure 88/40 mm Hg. B. Urinary output 40 mL/hr. C. Moderate rubra lochia. D. Heart rate 90/min.

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client in the postpartum unit. Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment?.

Correct Answer is D

Explanation

A nurse is caring for a client who is postpartum and just delivered a newborn who weighs 4.5 kg (10 lb). Which of the following manifestations should the nurse recognize as a potential sign of hemorrhage?

Correct Answer is A

Explanation

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