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. Kernicterus: Unrelated to postpartum complications; it is a bilirubin-related condition in newborns.
B. Uterine atony: Correct. A large infant increases the risk of uterine overstretching, leading to poor uterine contraction and postpartum hemorrhage.
C. Gestational diabetes: This is diagnosed during pregnancy, not as a postpartum complication.
D. Retained placental fragments: A possible concern but less likely than uterine atony in a client with a macrosomic infant.
Correct Answer is B
Explanation
A. Respiratory rate of 16 breaths/min: Normal range, no intervention needed.
B. Pulse of 120 beats per minute: Correct. Tachycardia in the postpartum period can indicate hemorrhage or hypovolemia, requiring immediate assessment and intervention.
C. Temperature of 98.8°F (37.7°C): Normal postpartum temperature.
D. Blood pressure of 120/88 mmHg: Normal postpartum blood pressure.
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