A postpartum client reports no bowel movement for 3 days and fears pain from her episiotomy. Which nursing action is most appropriate?
Offer a stool softener and increase fluid and fiber intake.
Administer an enema immediately.
Withhold oral intake until flatus is passed.
Encourage a low-fiber diet and rest.
The Correct Answer is A
Choice A reason: Stool softeners combined with increased fluid and fiber intake are the safest and most effective interventions. They prevent constipation, reduce straining, and minimize pain at the episiotomy site.
Choice B reason: Administering an enema is not the first-line intervention. It is invasive and may cause discomfort or trauma to the episiotomy site.
Choice C reason: Withholding oral intake until flatus is passed is inappropriate. Adequate nutrition and hydration are essential for recovery and bowel function.
Choice D reason: A low-fiber diet worsens constipation. Fiber is necessary to promote bowel motility and soften stool.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Two days postpartum, the uterus continues to involute and descends approximately 2 cm below the umbilicus. This is a normal finding in the process of uterine involution.
Choice B reason: By 1 week postpartum, the uterus is still palpable but has descended further into the pelvis. It does not become nonpalpable until about 2 weeks postpartum.
Choice C reason: The uterus does not remain an oval shape. After delivery, it gradually returns to its pre-pregnancy size and shape through involution.
Choice D reason: Immediately after delivery of the placenta, the uterus is about 2–3 cm above the umbilicus. This is not the expected finding 2 days postpartum.
Correct Answer is D
Explanation
Choice A reason: An increase in blood pressure is not a direct indicator of oxytocin’s effectiveness. Blood pressure changes may occur due to fluid shifts or vasoconstriction, but they do not confirm control of hemorrhage.
Choice B reason: An increase in lochia rubra would actually suggest worsening bleeding rather than improvement. Oxytocin should reduce blood loss by contracting the uterus, not increase it.
Choice C reason: Relief of afterpains is subjective and not a reliable measure of oxytocin’s effectiveness. Oxytocin often increases afterpains due to uterine contractions, so this is not a valid indicator.
Choice D reason: A firm uterus on palpation is the best indicator of oxytocin effectiveness. Oxytocin stimulates uterine smooth muscle contraction, which compresses blood vessels at the placental site, reducing hemorrhage. A firm uterus means bleeding is controlled.
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