A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders?
The woman had a vacuum-assisted birth.
The woman is a gravida 2, para 2.
The woman has an episiotomy.
The woman received epidural anesthesia.
The Correct Answer is C
A. The woman had a vacuum-assisted birth. While vacuum-assisted births can cause perineal trauma, the specific orders for ice packs, sitz baths, and stool softeners are more directly related to an episiotomy, which involves a surgical incision that requires careful postpartum care.
B. The woman is a gravida 2, para 2. This information indicates the woman's obstetric history but does not directly correlate with the need for perineal ice packs, sitz baths, and stool softeners. These orders are more specific to perineal trauma or surgical intervention.
C. The woman has an episiotomy. An episiotomy involves a surgical cut made at the opening of the vagina during childbirth, which can cause significant perineal pain and swelling. The orders for perineal ice packs, sitz baths, and stool softeners are intended to manage pain, reduce swelling, and prevent constipation, which can be particularly uncomfortable with perineal stitches.
D. The woman received epidural anesthesia. While epidural anesthesia is a common pain management technique during labor, it does not necessitate the use of perineal ice packs, sitz baths, or stool softeners postpartum. These orders are more indicative of perineal trauma or surgical intervention such as an episiotomy.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Human placental lactogen (hPL) is a hormone produced by the placenta that helps regulate the metabolism of the mother and fetus, but it is not used as the basis for pregnancy tests. It plays a role in modulating the metabolic state of the mother during pregnancy to facilitate the energy supply of the fetus.
B. Estrogen (estriol) is another hormone produced by the placenta, which is important for maintaining pregnancy and preparing the body for childbirth. However, it is not the hormone detected by pregnancy tests. Estriol levels increase significantly during pregnancy but are not used as a marker for pregnancy tests.
C. Progesterone (progestin) is crucial for maintaining the uterine lining and supporting early pregnancy. While it is essential for a successful pregnancy, it is not the hormone that pregnancy tests detect. Progesterone helps prevent uterine contractions and supports the endometrium.
D. Human chorionic gonadotropin (hCG) is the hormone detected by pregnancy tests. It is produced by the placenta shortly after the embryo attaches to the uterine lining. The presence of hCG in the blood or urine is a reliable indicator of pregnancy, which is why it is the basis for pregnancy tests.
Correct Answer is D
Explanation
Choice A reason:
Measuring urinary output. This is not the priority nursing care associated with an oxytocin infusion, because urinary output is not directly affected by oxytocin. Urinary output may be affected by other factors, such as fluid intake, dehydration, or kidney function, but these are not related to oxytocin administration. • Choice B reason:
Evaluating cervical dilation. This is also not the priority nursing care associated with an oxytocin infusion, because cervical dilation is a result of uterine contractions, not oxytocin itself. Oxytocin is used to stimulate or augment uterine contractions, but it does not cause cervical dilation directly. Cervical dilation is important to monitor during labor, but it is not the main focus of oxytocin infusion. • Choice C reason:
Increasing infusion rate every 30 minutes. This is not the priority nursing care associated with an oxytocin infusion, because increasing the infusion rate every 30 minutes is not a standard protocol for oxytocin administration. The infusion rate should be adjusted according to the patient's response and the provider's orders, but not arbitrarily or routinely. Increasing the infusion rate too quickly or too often can cause hyperstimulation of the uterus, which can be dangerous for both the mother and the fetus.
• Choice D reason:
Monitoring uterine response. This is the correct answer and the priority nursing care associated with an oxytocin infusion, because oxytocin can cause excessive or prolonged uterine contractions, which can lead to fetal distress, uterine rupture, or placental abruption. Therefore, the nurse must monitor the frequency, duration, and intensity of uterine contractions, as well as the fetal heart rate and blood pressure, to ensure that oxytocin is having the desired effect and not causing any adverse outcomes.
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