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

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.

A. Have her do Kegel exercises once an hour. B. Apply ice to her perineal area. C. Keep her hips slightly elevated. D. Observe her perineal area for signs of infection.

Correct Answer is B

Explanation

The correct answer is choice B. Apply ice to her perineal area.This is because ice can help reduce swelling and pain in the episiotomy wound, which is a cut made in the tissue between the vagina and anus during childbirth.Ice should be applied for the first 24 to 48 hours after delivery.

Choice A is wrong because Kegel exercises, which involve contracting and relaxing the pelvic floor muscles, are not recommended for the first 12 hours after an episiotomy.They can increase blood flow and inflammation in the area, and may interfere with healing.

Choice C is wrong because keeping her hips slightly elevated can cause pressure on the episiotomy wound and increase discomfort.It can also affect blood circulation and drainage in the area.

Choice D is wrong because observing her perineal area for signs of infection is not a nursing action that should be included in her plan of care for the first 12 hours.Infection is rare in episiotomy wounds, and signs of infection usually appear after 24 hours or later.However, the nurse should teach the patient how to keep the area clean and dry, and when to report any signs of infection, such as fever, pus, or foul-smelling discharge.

Normal ranges for episiotomy healing are:

• Stitches dissolve within 2 to 4 weeks

• Pain and swelling subside within a few days to a week

• Wound heals completely within 4 to 6 weeks

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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

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

A patient had an episiotomy during her delivery. Which nursing action should be included in her plan of care for the first 12 hours?

Correct Answer is B

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?