During the postpartal admission assessment, the nurse notes that a patient’s perineum appears edematous and ecchymotic.
Based on this finding, which action should the nurse take?
Observe the patient for vaginal discharge of bright red blood.
Assess the patient’s vaginal tone.
Massage the patient’s perineum.
Apply petrolatum to the patient’s perineum.
The Correct Answer is D
The correct answer is choice D. Apply petrolatum to the patient’s perineum. This is because petrolatum can help soothe and protect the perineal area, which may be swollen, bruised, or have stitches after a vaginal delivery. Applying petrolatum can also prevent the pad from sticking to the wound and causing more pain.
Choice A is wrong because observing the patient for vaginal discharge of bright red blood is not a specific action for perineal care. Bright red blood may indicate postpartum hemorrhage, which requires immediate medical attention.
Choice B is wrong because assessing the patient’s vaginal tone is not a priority action for perineal care. Vaginal tone may be reduced after childbirth due to stretching of the pelvic floor muscles, but this can improve with time and exercises.
Choice C is wrong because massaging the patient’s perineum is not recommended for perineal care. Massaging the perineum may cause more trauma and discomfort to the area, especially if there are stitches or hemorrhoids. Massaging the fundus (the top of the uterus) may be done to help it contract and prevent bleeding, but this is different from massaging the perineum.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Gestational age of 35-38 weeks.
This is because preterm babies are more likely to develop jaundice due to their immature liver and increased breakdown of red blood cells.Babies born between 35 and 38 weeks are considered late preterm and have a higher risk of jaundice than full-term babies.
Choice A is wrong because African American ethnicity is not a risk factor for jaundice.In fact, Asian, European, or native American ethnicity are more associated with jaundice.
Choice B is wrong because meconium-stained amniotic fluid is not a risk factor for jaundice.
Meconium is the first stool of the baby and it may indicate fetal distress, but it does not affect the bilirubin level.
Choice C is wrong because bottle feeding is not a risk factor for jaundice.In fact, breastfeeding is more associated with jaundice due to dehydration and poor caloric intake.
Correct Answer is C
Explanation
The correct answer is choice C. Count the time from the beginning of one contraction to the end of the same contraction.
This is because the duration of a contraction is the length of time that the uterine muscle is tightening and relaxing.
The duration is measured from the start of one contraction until the end of that same contraction.
Choice A is wrong because it measures the frequency of contractions, not the duration.
The frequency is the time between the start of one contraction and the start of the next one.
Choice B is wrong because it measures only half of the duration of a contraction.
The middle of a contraction is when the uterine muscle reaches its peak intensity and then starts to relax.
Choice D is wrong because it measures both the duration and the interval of contractions.
The interval is the time between the end of one contraction and the start of the next one.
Normal ranges for contractions during labor are:
• Duration: 30 to 90 seconds
• Frequency: 2 to 5 minutes apart
• Interval: 30 to 120 seconds
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