“A nurse is caring for a patient who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?”

Choice A rationale
Providing the client with a cool sitz bath can help soothe the perineal area, reduce inflammation, and promote healing after a fourth-degree laceration.
Choice B rationale
Administering methylergonovine IM is typically used for the prevention and treatment of postpartum or post-abortion hemorrhage caused by uterine atony or subinvolution. It would not directly address the care of a fourth-degree perineal laceration.
Choice C rationale
Applying a moist, warm compress to the perineum can provide some relief from discomfort, but a cool compress or sitz bath is typically recommended initially after a perineal laceration to help reduce swelling.
Choice D rationale
Applying povidone-iodine to the client’s perineum after she voids is not typically part of the care for a fourth-degree perineal laceration. The area should be kept clean, but routine application of antiseptics is not usually necessary.

Choice A rationale
Informing the client that the law requires them to name the fetus is not accurate. Laws vary by location, but most do not require parents to name a stillborn fetus. It is important to provide accurate information and support the parents in their decisions during this difficult time.
Choice B rationale
Limiting the amount of time the fetus is in the client’s room is not necessarily beneficial. Each family will have different needs and preferences when it comes to spending time with their stillborn baby. Some families may find comfort in holding and spending time with their baby, while others may prefer not to. The nurse should support the family’s decisions and provide compassionate care.
Choice C rationale
Instructing the client that an autopsy should be performed within 24 hours is not necessarily beneficial. The decision to perform an autopsy will depend on a variety of factors, including the parents’ wishes, the circumstances of the stillbirth, and local laws and regulations. It is important to provide the parents with information and support them in making this decision.
Choice D rationale
Providing the client with photos of the fetus can be a helpful part of the grieving process for some families. It allows them to remember their baby and can be a tangible reminder of the baby’s existence. However, this should be done based on the family’s wishes.