A woman gave birth vaginally to a 9-lb, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of sitz bath TID, and a stool softener. What information is most closely correlated with these orders?
The woman has laceration
The woman had her fourth baby
The woman received epidural anesthesia
The woman had a vacuum assisted birth
The Correct Answer is A
A. The woman has a laceration:
The orders for perineal ice packs, sitz baths, and a stool softener suggest that the woman may have sustained perineal trauma, such as a laceration, during childbirth. Ice packs are used initially to reduce swelling and discomfort, while a sitz bath helps with healing and soothing of the perineal area. Stool softeners are prescribed to prevent straining during bowel movements, which could worsen the discomfort of a laceration. These interventions are commonly recommended for women who experience perineal lacerations during vaginal delivery.
B. The woman had her fourth baby:
While the fact that this is the woman’s fourth pregnancy may influence her overall recovery, it is not directly correlated with the orders for ice packs, sitz baths, and stool softeners. Women who have had multiple children may be at a higher risk for perineal trauma due to the stretching of tissues, but this specific care plan is more likely related to a perineal injury, not the number of previous births.
C. The woman received epidural anesthesia:
Epidural anesthesia may be used to manage pain during labor, but it does not directly necessitate the use of ice packs, sitz baths, or stool softeners. While epidurals can sometimes lead to difficulty with bladder or bowel control, they do not typically cause perineal lacerations or require these specific interventions unless there is another issue, such as a laceration, that needs attention.
D. The woman had a vacuum-assisted birth:
Vacuum-assisted births can cause perineal trauma, including lacerations or hematomas, but the order for perineal care (ice packs, sitz baths, stool softeners) is not exclusively linked to vacuum assistance. The woman may have had a laceration during a vacuum-assisted delivery, but it is the laceration itself, rather than the use of the vacuum, that most directly correlates with these interventions. Therefore, the priority care focus is still on addressing the potential for perineal laceration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Pauses in respiration lasting 30 seconds:
Pauses lasting longer than 20 seconds or accompanied by other signs of distress would warrant further evaluation. A 30-second pause by itself, without additional concerning symptoms, is generally not a reason for immediate action.
B) Respiratory rate 36, crackles present bilaterally:
The presence of bilateral crackles is concerning. Crackles can indicate fluid in the lungs, possibly from retained amniotic fluid or respiratory distress syndrome (RDS). In a term newborn, bilateral crackles at this time, especially if accompanied by tachypnea or other signs of respiratory distress, may indicate a serious respiratory issue, such as aspiration pneumonia or RDS. Immediate assessment and intervention are necessary to ensure the infant is breathing adequately and that there are no underlying complications.
C) Apical heart rate of 160 with mild systolic murmur heard:
An apical heart rate of 160 is within the normal range for a newborn (typically 120-160 bpm). A mild systolic murmur is also not uncommon in newborns and may be benign, especially in the first few days of life. Murmurs are often transient and can be caused by normal circulatory changes as the newborn's cardiovascular system adjusts after birth. Although a heart murmur should be monitored, it is not typically an urgent concern unless associated with signs of poor perfusion or other cardiac symptoms.
D) Small white papules on nose and chin:
These small white papules are likely milia, which are common and harmless in newborns. Milia are keratin-filled cysts that typically appear on the face, especially around the nose and chin. They are a normal finding and resolve on their own without treatment. These papules do not require immediate action.
Correct Answer is A
Explanation
A) Mother Rh-, baby Rh+:
RhoGAM (Rh immune globulin) is administered to a mother who is Rh-negative and has delivered a baby who is Rh-positive. If the Rh-negative mother is exposed to Rh-positive blood (via the baby’s blood during delivery), her immune system may start producing antibodies against Rh-positive cells, which could affect future pregnancies. The RhoGAM injection works by preventing the mother from developing these antibodies, thereby protecting any subsequent pregnancies from hemolytic disease of the newborn (HDN) in which the mother’s antibodies attack the baby’s red blood cells. This is a crucial preventive measure to avoid sensitization to Rh-positive blood.
B) Mother Rh-, baby Rh-:
If both the mother and baby are Rh-negative, there is no concern about the development of antibodies because there is no exposure to Rh-positive blood. Therefore, RhoGAM is not necessary in this situation.
C) Mother Rh+, baby Rh+:
In this scenario, the mother is Rh-positive, so she cannot develop antibodies against Rh-positive blood, regardless of the baby's Rh status. Hence, RhoGAM is not required because there is no risk of Rh incompatibility.
D) Mother Rh+, baby Rh-:
Since the mother is Rh-positive, there is no risk of her immune system attacking an Rh-negative baby’s red blood cells. Thus, RhoGAM is not needed in this case either.
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