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. Encourage the client to drink cold, carbonated fluids throughout the day.This helps to relieve the shoulder pain caused by the carbon dioxide gas used to inflate the abdomen during laparoscopy.
The gas irritates the diaphragm, which refers pain to the shoulder.Drinking cold, carbonated fluids can help expel the gas and reduce the pain.
Choice A is wrong because an abdominal binder is not necessary for a laparoscopic procedure.It is more commonly used for abdominal surgeries that involve a large incision.
Choice B is wrong because a rocking chair is not helpful for a client who had a laparoscopic BTL.It is more useful for a client who had a vaginal delivery to promote comfort and uterine involution.
Choice C is wrong because keeping the head of the bed flat for six hours is not indicated for a laparoscopic BTL.It may increase the risk of venous thromboembolism and pulmonary embolism due to prolonged immobility.The client should be encouraged to ambulate as soon as possible after surgery.
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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