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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The correct answer is choice B. Dry off the newborn.This is the priority nursing action because it prevents heat loss and hypothermia in the newborn.

The newborn has a large surface area and a thin layer of subcutaneous fat, making it vulnerable to cold stress.Drying off the newborn also stimulates breathing and crying, which helps clear the airways.

Choice A is wrong because obtaining a serum sample is not a priority action and may cause unnecessary pain and bleeding in the newborn.

Choice C is wrong because assessing the newborn’s Moro reflex is not a priority action and may be done later during the physical examination.Choice D is wrong because obtaining the newborn’s footprints is not a priority action and may be done after the bonding and breastfeeding period.

A. What is the nurse’s best response to the client’s question as to why the amniocentesis test is being done?. B. “To determine fetal lung maturity.”. C. “To assess the degree of fetal renal function.”. D. “To test the amniotic fluid glucose level.”. E. “To detect the presence of fetal congenital anomalies.”.

Correct Answer is A

Explanation

The correct answer is choice A.“To determine fetal lung maturity.” An amniocentesis at 37 weeks of gestation can be done to measure the lecithin/sphingomyelin (L/S) ratio in the amniotic fluid, which indicates the level of surfactant production and the readiness of the fetal lungs for breathing.A low L/S ratio can indicate fetal compromise due to gestational diabetes.

Choice B is wrong because fetal renal function is not assessed by amniocentesis, but by ultrasound or biophysical profile.

Choice C is wrong because amniotic fluid glucose level is not a reliable indicator of fetal well-being or gestational diabetes control.

Choice D is wrong because congenital anomalies are usually detected earlier in pregnancy by ultrasound, maternal serum screening, or chorionic villus sampling.

Normal ranges for L/S ratio are 2:1 or higher for term fetuses and 1.5:1 or higher for preterm fetuses.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Just after a client delivers a baby who weighs 7 pounds (3.18 kg), what is the priority nursing action?

Correct Answer is B

Explanation

Question 71. A nurse is caring for a client who has gestational diabetes and is scheduled for an amniocentesis at 37 weeks of gestation due to suspected fetal compromise.

Correct Answer is A

Explanation

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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?