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 D

Explanation

The correct answer is choice D. Cesarean delivery.A pregnant patient with genital herpes is at higher risk of transmitting the infection to the baby during vaginal delivery, especially if there is an active outbreak near the time of birth.This can cause serious complications for the baby, such as brain damage, eye problems, or even death.Therefore, a cesarean delivery is recommended to avoid contact between the baby and the genital lesions.

Choice A is wrong because forceps-assisted second stage of labor is not a complication of genital herpes.

It is a method of assisted delivery that may be used for various reasons, such as fetal distress, maternal exhaustion, or abnormal presentation.

Choice B is wrong because precipitous delivery, which means a very fast labor and delivery, is not a complication of genital herpes.

It may be caused by factors such as multiparity, strong contractions, or previous rapid deliveries.

Choice C is wrong because prolonged first phase of labor, which means a slow dilation of the cervix, is not a complication of genital herpes.

It may be caused by factors such as ineffective contractions, large fetal size, or malposition.

A. Take the mother’s vital signs every 15 minutes. B. Send a specimen of the fluid to the laboratory for analysis. C. Have a suction catheter available for use at delivery. D. Prepare a slide of the fluid for fern testing.

Correct Answer is C

Explanation

The correct answer is choice C. Have a suction catheter available for use at delivery.This is because meconium-stained amniotic fluid indicates that the fetus has passed meconium (first stool) before birth, which can be a sign of fetal distress or hypoxia.Meconium can block the airways and cause breathing problems for the newborn, so suctioning the mouth and nose (or the trachea if needed) is important to prevent meconium aspiration syndrome.

Choice A is wrong because taking the mother’s vital signs every 15 minutes is not a specific intervention for meconium-stained amniotic fluid.

Vital signs should be monitored regularly during labor regardless of the fluid color.

Choice B is wrong because sending a specimen of the fluid to the laboratory for analysis is not a priority action.The color and consistency of the fluid can be observed by the nurse and documented.

The laboratory analysis will not change the immediate management of the newborn.

Choice D is wrong because preparing a slide of the fluid for fern testing is not relevant for meconium-stained amniotic fluid.

Fern testing is used to confirm the rupture of membranes by detecting a fern-like pattern of amniotic fluid under a microscope.It is not useful for assessing the presence or severity of meconium-stained amniotic fluid.

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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

When a pregnant patient has genital herpes, for which complication is the patient at higher risk than the general population?

Correct Answer is D

Explanation

A patient’s amniotic fluid is meconium-stained. Which action should the nurse plan to take?

Correct Answer is C

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?