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 B
Explanation
The correct answer is choice B: The risk of transplacental transmission of chlamydia between mother and baby is low.This means that the infection is unlikely to pass from the mother’s blood to the baby’s blood through the placenta.However, this does not mean that the infection is harmless for the baby.
Choice A is wrong because transmission of chlamydia usually occurs when the baby passes through the vagina.This can cause eye infections or pneumonia in the newborn.
Choice C is wrong because the baby has probably not developed antibodies to the chlamydia in utero.Antibodies are proteins that help fight infections, and they are usually passed from the mother to the baby through the placenta.However, chlamydia does not stimulate a strong antibody response in the mother, so there is little protection for the baby.
Choice D is wrong because the baby will not receive systemic treatment at birth to prevent a chlamydia infection.Systemic treatment means medication that affects the whole body, such as oral or intravenous antibiotics.The baby will only receive topical treatment, such as eye drops or ointment, to prevent eye infections.Normal ranges: Chlamydia infection is common among pregnant women, especially those under 25 years old or with risk factors such as multiple or new sexual partners.The prevalence of chlamydia among pregnant women in the United States ranges from 1% to 40%, depending on the population and screening methods.Chlamydia infection can be diagnosed by urine or swab tests, and treated with antibiotics such as azithromycin or doxycycline.Chlamydia screening is recommended for all pregnant women at their first prenatal visit and again in the third trimester if they are at high risk.
Correct Answer is A
Explanation
This means that the uterus is constantly contracted and does not relax between contractions.This can cause the placenta to separate from the uterine wall, which is called placental abruption or abruptio placentae.Placental abruption can deprive the baby of oxygen and nutrients and cause heavy bleeding in the mother.
Choice B is wrong because strong uterine contractions every 3-4 minutes are normal during labor and do not indicate placental abruption.
Choice C is wrong because bile-colored vomitus is not a sign of placental abruption, but rather a sign of hyperemesis gravidarum, a severe form of nausea and vomiting during pregnancy.
Choice D is wrong because fetal heart rate acceleration with fetal activity is a normal finding and indicates a healthy baby.Placental abruption can cause fetal distress and a decrease in fetal heart rate.
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