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.
Nursing Test Bank
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 A
Explanation
Choice A reason:
Obtaining blood glucose by heel stick is the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. These signs are suggestive of hypoglycemia, which is a common and potentially serious condition in newborns. Hypoglycemia can result from various causes, such as maternal diabetes, prematurity, intrauterine growth restriction, or perinatal stress. A heel stick is a simple and quick method to obtain blood samples from newborns for glucose testing.
Choice B reason:
Initiating phototherapy is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. Phototherapy is used to treat hyperbilirubinemia, which is a condition characterized by high levels of bilirubin in the blood. Hyperbilirubinemia can cause jaundice, which is a yellowish discoloration of the skin and eyes. Jaundice does not typically cause diaphoresis, jitteriness, or lethargy in newborns.
Choice C reason:
Monitoring the newborn's blood pressure is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. Blood pressure measurement is not routinely performed in healthy newborns. Blood pressure may be indicated in newborns who have signs of cardiovascular compromise, such as cyanosis, tachycardia, or poor perfusion. Diaphoresis, jitteriness, and lethargy are not specific signs of cardiovascular compromise in newborns.
Choice D reason:
Placing the newborn in a radiant warmer is not the appropriate action for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy. A radiant warmer is a device that provides heat to maintain the newborn's body temperature. A radiant warmer may be used for newborns who are at risk of hypothermia, such as those who are premature, have low birth weight, or have cold stress. Diaphoresis, jitteriness, and lethargy are not specific signs of hypothermia in newborns.
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