A nurse is planning care for a postpartum client who expresses a desire to follow the traditional beliefs regarding the balance of yin and yang for postpartum care.
Which of the following actions should the nurse plan to take?
Apply a new ice pack to the client's perineal area every 4 hours.
Maintain a cool environment in the client's room.
Provide the client with a warm beverage.
Assist the client with showering twice daily.
The Correct Answer is C
Choice A rationale
Applying ice packs aligns with Western medical practices for reducing swelling and pain. However, traditional yin and yang beliefs often emphasize warmth during the postpartum period to restore a perceived loss of "hot" energy after childbirth. Cold applications could be seen as counterproductive to this balance.
Choice B rationale
Maintaining a cool environment would contradict the traditional belief in maintaining warmth for the postpartum client. In many cultures, a "hot-cold" theory dictates that the postpartum period is a "cold" state, requiring warmth to restore balance and prevent illness. A cool room would be perceived as harmful.
Choice C rationale
Providing a warm beverage aligns with traditional yin and yang postpartum care. Childbirth is often seen as a significant loss of "yang" energy (warmth, activity). Consuming warm foods and beverages helps to replenish this energy, promoting restoration of balance and preventing "cold" illnesses according to this belief system.
Choice D rationale
Showering twice daily, especially with cool water, might conflict with traditional postpartum practices that often restrict bathing or emphasize warm baths. The concern is often about preventing "cold" from entering the body and disrupting the balance, as well as conserving energy during a vulnerable period.
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Correct Answer is B
Explanation
Choice A rationale
A temperature of 37.7° C (99.9° F) in the immediate postpartum period is a relatively common and often benign finding, typically within normal limits or indicating mild dehydration or exertion from labor. A slight elevation is not usually a cause for immediate concern unless accompanied by other signs of infection, which would warrant further investigation. Normal range is 36.5° C to 37.5° C (97.7° F to 99.5° F).
Choice B rationale
A boggy fundus is a significant finding that the nurse should report immediately. A boggy, soft uterus indicates uterine atony, which means the uterine muscles are not contracting effectively. This significantly increases the risk of postpartum hemorrhage due to inadequate compression of uterine blood vessels.
Choice C rationale
Lochia rubra with small clots is considered a normal finding in the immediate postpartum period. Lochia rubra is the initial dark red discharge consisting of blood, decidual tissue, and mucus. Small clots are expected as blood clots and detaches from the uterine wall, reflecting normal uterine involution.
Choice D rationale
Minimal perineal edema is a normal and expected finding after vaginal delivery. The trauma of childbirth often results in some degree of swelling in the perineal area. "Minimal" edema indicates that the swelling is not excessive and does not suggest a complication requiring immediate reporting to the provider.
Correct Answer is B
Explanation
Choice A rationale
While monitoring vital signs (temperature, heart rate, and blood pressure) is important for overall maternal assessment, in the context of strong contractions and reported nausea/urge to defecate, these specific vital signs are not the immediate priority for identifying the most critical complication. Normal temperature is 36.5-37.5°C, heart rate 60-100 bpm, blood pressure 90/60 to 120/80 mmHg.
Choice B rationale
The client's symptoms (strong contraction, nausea, urge to defecate) strongly suggest the second stage of labor, specifically an urge to push. The highest priority is to determine the fetal heart rate in relationship to the contraction, as this immediate assessment evaluates fetal well-being and detects potential distress, like late decelerations, indicating uteroplacental insufficiency.
Choice C rationale
Examining vaginal discharge for meconium is important if there are signs of fetal distress, but assessing the fetal heart rate pattern in relation to contractions directly provides real-time information about fetal oxygenation and is therefore the immediate priority when assessing labor progress with these symptoms.
Choice D rationale
Performing a vaginal examination to assess labor progress is a crucial step to confirm cervical dilation and fetal descent. However, before internal examination, ensuring fetal well-being through external monitoring of the fetal heart rate during contractions is paramount, especially with the client's reported symptoms suggesting advanced labor.
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