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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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. G2P1 (second pregnancy, one prior birth) may experience some afterbirth pains, but G3P2 is at higher risk.

B. Multiparous clients (those who have had multiple pregnancies) are more likely to experience stronger afterbirth pains due to repeated uterine stretching and contractions. Additionally, delivering a large baby (macrosomia) increases uterine involution and associated pain.

C. First-time mothers (G1P1) typically experience milder afterbirth pains due to a less stretched uterus.

D. G3P0 (three pregnancies, no births) suggests preterm labor without full-term delivery, making afterbirth pains unlikely.

A. level of umbilicus B. 1 fingerbreadth/cm below umbilicus C. 2 fingerbreadth/cm below umbilicus D. 3 fingerbreadth/cm below umbilicus

Correct Answer is C

Explanation

A. This is expected immediately postpartum.

B. This is expected at 24 hours postpartum.

C. Immediately after birth, the fundus is at the level of the umbilicus. The uterus involutes (shrinks) approximately 1 cm (or 1 fingerbreadth) per day postpartum. 48 hours postpartum, the fundus should be 2 cm (or 2 fingerbreadths) below the umbilicus.

D. 3 cm below the umbilicus would be expected at 72 hours postpartum.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following clients is most likely to complain of afterbirth pains during her postpartum period?

Correct Answer is B

Explanation

You are assessing a patient who delivered vaginally 48 hours ago. At this time, where would you expect to feel her fundus?

Correct Answer is C

Explanation

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