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. The client should avoid sexual intercourse.Sexual intercourse may stimulate uterine contractions and increase the risk of preterm labor.The client should also avoid activities that may cause dehydration, infection, or stress.

Choice A is wrong because documenting urine output hourly is not necessary for a client with preterm labor who is discharged home.Urine output may be affected by hydration status, kidney function, or medication use, but it is not a reliable indicator of preterm labor.

Choice C is wrong because maintaining a darkened, quiet environment is not required for a client with preterm labor who is discharged home.The client may benefit from rest and relaxation, but there is no evidence that light or noise affects preterm labor.

Choice D is wrong because eating small, frequent meals is not specific to a client with preterm labor who is discharged home.Eating small, frequent meals may help with nausea, heartburn, or blood sugar control, but it does not prevent preterm labor.

A. Rubella immunization should be given in the early postpartum period. B. Gamma globulin should be given when the client is admitted in labor. C. Gamma globulin should be given at next visit. D. Rubella immunization should be given at next visit.

Correct Answer is A

Explanation

Rubella immunization should be given in the early postpartum period.This is because rubella infection during pregnancy can cause serious birth defects or miscarriage, and rubella vaccine is contraindicated during pregnancy.Therefore, the best time to vaccinate a woman who is not immune to rubella is after she delivers her baby.

Choice B is wrong because gamma globulin is not effective for preventing rubella infection or congenital rubella syndrome (CRS).Gamma globulin is a preparation of antibodies that can provide temporary protection against some infections, but it does not induce lasting immunity.

Choice C is wrong because gamma globulin should not be given at the next visit for the same reason as choice B.Moreover, gamma globulin can interfere with the response to live vaccines such as rubella vaccine, so it should not be given within 3 months before or after vaccination.

Choice D is wrong because rubella immunization should not be given at the next visit or during pregnancy, as it can pose a risk to the fetus.Rubella vaccine is a live attenuated virus vaccine that can cross the placenta and infect the fetus.The risk of CRS from vaccination during pregnancy is low, but it cannot be ruled out completely.Therefore, women who receive rubella vaccine should avoid pregnancy for at least 4 weeks after vaccination.

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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

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Correct Answer is B

Explanation

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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?