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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A) Rubra, serosa, alba:
The normal progression of lochia, the vaginal discharge after childbirth, follows a predictable sequence of stages. Lochia rubra is the initial stage, occurring within the first few days postpartum. It is bright red and consists primarily of blood, tissue, and debris from the placenta. After 3-4 days, the discharge changes to lochia serosa, which is pinkish-brown and contains a mixture of blood, serous fluid, and mucous. After 10-14 days, it progresses to lochia alba, which is white or pale yellow and consists mostly of leukocytes (white blood cells), mucus, and epithelial cells. This is the expected progression, which marks the natural healing process after childbirth.

B) Rubra, alba, serosa:
This order is incorrect because lochia serosa comes before lochia alba in the normal sequence. Lochia alba occurs after lochia serosa, not before. This progression would not accurately reflect the typical stages of lochia.

C) Serosa, alba, rubra:
This sequence is incorrect as lochia rubra is the first stage, not lochia serosa. The initial discharge following childbirth is always red and blood-tinged, which is lochia rubra. Serosa and alba come later in the progression, so this order does not follow the correct timeline.

D) Alba, rubra, serosa:
This order is completely incorrect. Lochia rubra (red blood discharge) is the first stage, not lochia alba (white discharge). After childbirth, rubra occurs first, followed by serosa, and then finally alba. This sequence does not reflect the normal postpartum discharge process.

A. Has at least six to eight wet diapers per day B. Sleeps for 6 hours at a time between feedings C. Gains 1 to 2 ounces per week D. Has at least one breast milk stool every 24 hours

Correct Answer is A

Explanation

A) Has at least six to eight wet diapers per day:
One of the most reliable signs of effective breastfeeding is adequate hydration and urine output, which can be assessed by the number of wet diapers. A well-fed infant should have at least six to eight wet diapers per day, indicating that they are taking in sufficient breast milk and are adequately hydrated. This is a key indicator of successful breastfeeding and helps to ensure that the baby is getting enough milk.

B) Sleeps for 6 hours at a time between feedings:
While it is normal for newborns to sleep, they should not go for long periods without feeding, especially in the early days of life. Newborns typically need to be fed every 2 to 3 hours, and a sleep pattern of 6 hours between feedings could be concerning, as it may indicate that the baby is not waking up frequently enough to eat. This could result in inadequate milk intake and dehydration. Breastfeeding on demand is important, and frequent feedings help to stimulate milk production.

C) Gains 1 to 2 ounces per week:
A typical weight gain for a newborn is about 4 to 7 ounces per week during the first few months of life. Gaining 1 to 2 ounces per week could be lower than expected, and while weight gain is an important indicator of breastfeeding effectiveness, it is not the most immediate or reliable sign in the first week, especially if the baby is otherwise feeding well and producing an adequate number of wet diapers.

D) Has at least one breast milk stool every 24 hours:
While it is normal for a newborn to have breast milk stools, the frequency can vary widely. Some infants may pass stools after every feeding, while others may have fewer. One stool every 24 hours is not necessarily a sign of inadequate breastfeeding, especially if the baby is having a good number of wet diapers. The stool pattern can differ from baby to baby, and as long as the infant is feeding well and producing sufficient wet diapers, stool frequency alone is not the best indicator of breastfeeding success.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Lochia progresses in the following order:

Correct Answer is A

Explanation

A postpartum woman telephones about her 6-day-old infant. She is not scheduled for, weight check until the infant is 10 days old, and she is worried about whether breastfeeding going well. Effective breastfeeding is best indicated by the newborn who:

Correct Answer is A

Explanation

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Which of the following nursing interventions will promote comfort for a client with a labial first degree laceration? Select all that apply.