A postpartum client sustained a fourth-degree perineal laceration during vaginal delivery. The nurse is developing a care plan focused on promoting healing and preventing complications. Which combination of interventions best addresses the unique challenges of this type of injury?
Administer prescribed stool softeners, maintain strict perineal hygiene with warm water rinses, encourage use of a peri-bottle, and monitor for signs of urinary retention and infection.
Encourage immediate ambulation, restrict oral fluids, apply cold compresses to the perineum, and teach avoidance of Kegel exercises for 6 weeks.
Limit the use of pain medication to observe for infection, encourage frequent sitz baths starting 24 hours after delivery, and restrict dietary fiber to prevent diarrhea.
Promote frequent use of strong laxatives to prevent constipation, discourage perineal cleansing to avoid imitation, and advise delaying follow-up appointments until 6 weeks postpartum.
The Correct Answer is A
A. Fourth-degree lacerations extend through the rectal mucosa, making infection and wound dehiscence major concerns. Stool softeners prevent straining, while perineal hygiene and peri-bottle use reduce bacterial contamination. Monitoring for urinary retention ensures early detection of pelvic floor dysfunction or trauma-related swelling.
B. While ambulation aids circulation, restricting fluids can cause dehydration and constipation. Avoiding Kegel exercises delays pelvic floor strengthening, which supports healing. Cold compresses are beneficial initially but should not replace hygiene and bowel care.
C. Limiting pain control can impair mobility and self-care. Dietary fiber restriction worsens constipation and straining, which increase pain and risk of wound disruption. Sitz baths are beneficial but not sufficient alone for complete care.
D. Strong laxatives can cause diarrhea and trauma to sutures, while inadequate cleansing heightens infection risk. Early follow-up is crucial for wound assessment, making delayed appointments unsafe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Fourth-degree lacerations extend through the rectal mucosa, making infection and wound dehiscence major concerns. Stool softeners prevent straining, while perineal hygiene and peri-bottle use reduce bacterial contamination. Monitoring for urinary retention ensures early detection of pelvic floor dysfunction or trauma-related swelling.
B. While ambulation aids circulation, restricting fluids can cause dehydration and constipation. Avoiding Kegel exercises delays pelvic floor strengthening, which supports healing. Cold compresses are beneficial initially but should not replace hygiene and bowel care.
C. Limiting pain control can impair mobility and self-care. Dietary fiber restriction worsens constipation and straining, which increase pain and risk of wound disruption. Sitz baths are beneficial but not sufficient alone for complete care.
D. Strong laxatives can cause diarrhea and trauma to sutures, while inadequate cleansing heightens infection risk. Early follow-up is crucial for wound assessment, making delayed appointments unsafe.
Correct Answer is ["A","B","C","D","E"]
Explanation
A. The fetus is in engagement, and further descent is expected as labor progresses: A fetal station of 0 means the presenting part is at the level of the ischial spines, confirming engagement. Continued descent is expected as contractions increase in strength and frequency.
B. Immediate provider notification is not required, but continued monitoring is necessary for signs of labor progression: The findings reflect normal active labor progress. The nurse should continue monitoring maternal and fetal status, documenting changes, and supporting the client through ongoing cervical dilation and fetal descent.
C. Although the patient is not yet in transition, contractions are likely becoming more intense and closer together: At 6 cm dilation, the client is in the active phase of labor, where contractions typically occur every 3–5 minutes and increase in intensity as the cervix continues to dilate toward the transition phase.
D. Fetal station indicates the presenting part is at the level of the ischial spines: A station of 0 identifies the presenting fetal part as aligned with the ischial spines, representing the narrowest part of the maternal pelvis and confirming engagement.
E. Complete effacement with 6 cm dilation indicates favorable cervical change and progression: Full effacement and progressive dilation are reassuring signs that the cervix is responding effectively to uterine contractions and that labor is advancing normally.
F. The cervix is fully dilated and the patient will begin pushing soon: Full dilation is 10 cm, not 6 cm. The client is still in the active phase and should not begin pushing until complete dilation is achieved to prevent cervical trauma or fatigue.
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