A nurse is caring for a client who is 5 days postpartum and has a vaginal birth with an episiotomy.
The client reports that she has pain in her perineal area and asks the nurse what she can do to relieve the discomfort.
“Apply heat to your perineum.”
“You should increase your fluid intake.”
.“You should increase your fiber intake.”
“You should avoid straining during bowel movements.”.
The Correct Answer is D
The correct answer is choice D. “You should avoid straining during bowel movements.” This is because straining can cause pain and bleeding in the perineal area, especially if the client has an episiotomy or hemorrhoids. Straining can also worsen the damage to the pelvic floor muscles or the anal sphincter muscles that might have occurred during delivery.
Choice A is wrong because taking a laxative can cause diarrhea, dehydration, and electrolyte imbalance. Laxatives should only be used if prescribed by a health care provider.
Choice B is wrong because increasing fluid intake alone is not enough to prevent or treat constipation. Fluid intake should be combined with adequate fiber intake and physical activity.
Choice C is wrong because increasing fiber intake alone is not enough to prevent or treat constipation. Fiber intake should be combined with adequate fluid intake and physical activity.
Normal ranges for fluid intake are about 2 to 3 liters per day for a lactating woman and about 1.5 to 2 liters per day for a non-lactating woman. Normal ranges for fiber intake are about 25 to 35 grams per day for adults. Normal ranges for physical activity are about 150 minutes of moderate-intensity exercise per week for healthy adults.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Palpate the fundus for firmness.This is because an unpleasant odor of lochia (postpartum vaginal discharge) can indicate an infection or retained placental fragments in the uterus.Palpating the fundus can help assess the uterine involution and detect any abnormalities.
Choice A is wrong because documenting the finding is not enough to address the potential problem.The nurse should also notify the provider and take further actions as ordered.
Choice B is wrong because encouraging the woman to empty her bladder regularly is not related to the odor of lochia.It is a general measure to prevent urinary tract infections and promote uterine contraction.
Choice D is wrong because administering oxytocics as prescribed is not a nursing action for lochia with an unpleasant odor.Oxytocics are drugs that stimulate uterine contractions and are used to prevent or treat postpartum hemorrhage.
They do not affect the infection or retention of placental fragments.
Normal ranges for lochia are:
• Lochia rubra: dark or bright red blood, lasts for 3 to 4 days, flows like a heavy period, small clots are normal.
• Lochia serosa: pinkish brown discharge, lasts for 4 to 12 days, thinner and more watery than lochia rubra, moderate flow, less or no clots.
• Lochia alba: yellowish white discharge, lasts from 12 days to 6 weeks, light flow or spotting, no clots.
Lochia should have a stale, musty or metallic odor like menstrual blood.It should not smell fishy or foul, which can indicate an infection.
Correct Answer is B
Explanation
The correct answer is choice B. Sexual intercourse may be uncomfortable due to vaginal dryness.According to Mayo Clinic, hormonal changes after pregnancy might leave the vagina dry and tender, especially if the client is breast-feeding.
This can cause pain and discomfort during sex.
The client can use lubricant or try alternative forms of intimacy to ease the discomfort.
Choice A is wrong because sexual intercourse can be resumed after 4 weeks postpartum only if the client feels comfortable and has no complications.The general recommendation is to wait until 6 weeks postpartum or until the provider clears the client for sex.
Choice C is wrong because sexual intercourse should not be avoided until lochia alba stops.
Lochia alba is the last stage of postpartum bleeding that lasts from 10 to 14 days after delivery.The client can resume sex before lochia alba stops if they feel ready and use contraception to prevent pregnancy.
Choice D is wrong because sexual intercourse may not cause uterine bleeding or infection if the client follows proper hygiene and uses protection.The risk of complications is highest during the first two weeks after delivery, but it decreases after that.
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