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 A

Explanation

Choice A reason:
At 37 weeks, especially in gestational diabetes, fetal lungs may still be immature. Amniocentesis checks lung maturity to ensure the baby can breathe effectively if early delivery is needed due to fetal compromise.

Choice B reason:
Fetal renal function is not typically assessed through amniocentesis at term. Kidney function is monitored via ultrasound, not by analyzing amniotic fluid at 37 weeks.

Choice C reason:
Amniotic fluid glucose levels are not used to manage gestational diabetes. Maternal blood glucose is the standard for monitoring and treatment.

Choice D reason:
Congenital anomalies are usually detected earlier in pregnancy. By 37 weeks, the focus of amniocentesis is on delivery planning, not anomaly detection.

A. “You don’t need to breastfeed now if you would rather wait for your milk to come in.”. B. “It is good practice for you to breastfeed now so that you will be skilled when your milk comes in.”. C. “The earlier you begin to breastfeed your baby, the closer you and your baby may become.”. D. “The fluid you have in your breasts now is just what the baby needs.”.

Correct Answer is D

Explanation

The correct answer is choice D. The fluid that the mother has in her breasts before the milk comes in is called colostrum, which is rich in antibodies and nutrients that the baby needs.

It also helps to prevent jaundice by stimulating the baby’s bowel movements.

Therefore, the nurse should encourage the mother to breastfeed as soon as possible after birth and explain the benefits of colostrum.

Choice A is wrong because it discourages breastfeeding and may interfere with milk production and bonding.

Choice B is wrong because it implies that breastfeeding is only a skill and not a natural process that benefits both the mother and the baby.

Choice C is wrong because it focuses on the emotional aspect of breastfeeding and not the physiological one.

While breastfeeding may enhance the closeness between the mother and the baby, it is not the only reason to breastfeed.

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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

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. What is the nurse’s best response to the client’s question as to why the amniocentesis test is being done?

Correct Answer is A

Explanation

During the first postpartum day, a new mother is breastfeeding her infant.The client asks, “Since I don’t have any milk yet, why am I breastfeeding?” Which response by the nurse is most appropriate?

Correct Answer is D

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?