A nurse is caring for a postpartum client, who delivered yesterday and complains of constipation.
She had a vaginal delivery complicated by a fourth degree laceration, which was repaired.
Based upon this information, which of the following is contraindicated?
Increase fluid intake to 2-3 L/day.
Stool softeners as needed.
Increase fiber intake.
Rectal suppository as needed.
The Correct Answer is D
Choice A rationale
Increasing fluid intake to 2-3 L/day is recommended to prevent dehydration and promote overall health. Adequate hydration can also help soften stools and prevent constipation.
Choice B rationale
Stool softeners are often recommended for postpartum clients, especially those with perineal trauma, to ease bowel movements and prevent straining. They help soften the stool, making it easier to pass without causing additional pain or injury.
Choice C rationale
Increasing fiber intake is beneficial for preventing constipation. High-fiber foods, such as fruits, vegetables, and whole grains, add bulk to the stool and promote regular bowel movements.
Choice D rationale
Rectal suppositories are contraindicated for clients with a fourth-degree laceration. Inserting a suppository can cause trauma to the perineal area and increase the risk of infection or further injury. Alternative methods to manage constipation should be considered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Encouraging the client to empty her bladder is a common practice to prevent uterine atony and excessive bleeding. However, in this scenario, the fundus is already midline and firm at the umbilicus, indicating that the uterus is well-contracted. Therefore, this action is not necessary.
Choice B rationale
Notifying the client’s provider is not required in this situation. The findings of a light amount of lochia rubra and a firm, midline fundus are normal for 6 hours postpartum. There are no signs of complications that would necessitate contacting the provider.
Choice C rationale
Documenting the findings and continuing to monitor the client is the appropriate action. The client’s condition is stable, and the findings are within the expected range for 6 hours postpartum. Ongoing monitoring will ensure that any changes in the client’s condition are promptly addressed.
Choice D rationale
Increasing the frequency of fundal massage is not needed in this case. The fundus is already firm and midline, indicating that the uterus is well-contracted. Excessive fundal massage can cause discomfort and is unnecessary when the uterus is already in a good position.
Correct Answer is B
Explanation
Choice A rationale
A 29-year-old G3P3003 with an uncomplicated SVD at term and a supportive family environment is less likely to experience difficulties in transitioning to motherhood. The presence of her husband and older daughter provides a strong support system, which is beneficial for her adjustment.
Choice B rationale
A 37-year-old G3P1112 with worsening preeclampsia, induced at 34 weeks, currently on Magnesium Sulfate, and with a baby in the NICU, faces multiple stressors. The medical complications, preterm delivery, and separation from her baby due to NICU admission increase her risk for a difficult transition to motherhood. The use of Magnesium Sulfate can also affect her physical and emotional well-being.
Choice C rationale
A 31-year-old G3P2012 with a history of depression and a husband who is deployed faces significant challenges. The history of depression increases her risk for postpartum depression, and the absence of her husband can lead to feelings of isolation and increased stress.
Choice D rationale
A 16-year-old G1P1001 who delivered via cesarean section is at risk due to her young age and the surgical delivery. Adolescents may have less experience and resources to cope with the demands of motherhood, and the recovery from a cesarean section can add to the physical and emotional challenges.
Choice E rationale
A 20-year-old G1P1001 with an uncomplicated SVD and the presence of her boyfriend is less likely to face significant difficulties. The uncomplicated delivery and the support of her boyfriend provide a stable environment for her transition to motherhood. .
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.