A nurse is reviewing the prescribed orders for a client who is two days postpartum and has a fourth degree perineal laceration. Which of these orders should the nurse question?
Administer acetaminophen for pain
Encourage oral fluids
Administer a sitz bath
Administer an Enema
The Correct Answer is D
A. Acetaminophen is an appropriate analgesic for postpartum pain relief.
B. Encouraging oral fluids is essential for hydration, bowel function, and healing.
C. A sitz bath is beneficial for perineal healing, reducing pain and inflammation.
D. Correct. Enemas are contraindicated in clients with fourth-degree perineal lacerations because they may cause trauma, pain, and further damage to the perineal area. Stool softeners are preferred to prevent straining.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Supporting the uterus decreases the amount of pain." Incorrect. While proper support may reduce discomfort, the primary reason is structural support.
B. "This is necessary because the ligaments that hold the uterus are stretched." Correct. The uterus is enlarged postpartum, and the ligaments are weakened, making support necessary.
C. "This will decrease the severity of uterine bleeding." Not the primary reason, though proper fundal massage can aid in hemorrhage prevention.
D. "This will help with uterine involution." Incorrect. Uterine involution is driven by hormonal changes and contractions, not just support.
Correct Answer is ["A","B","D"]
Explanation
A. Licking or smacking lips is an early sign of hunger.
B. Hand-to-mouth movements indicate readiness to feed.
C. Sleeping is not a feeding cue; babies may need to be woken for feedings.
D. Sucking on fingers is an early hunger sign.
E. Smiling is not associated with feeding readiness.
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