A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday.
Her primary health care provider has written orders for perineal ice packs, use of a sitz bath, and a stool softener.
What information is most closely correlated with these orders?
The woman received epidural anesthesia.
The woman has an episiotomy or a laceration of the perineum.
The woman is a gravida 2, para 2.
The woman had a vacuum-assisted birth.
The Correct Answer is B
Choice A rationale
Epidural anesthesia is primarily associated with difficulty voiding and potential headaches, but it does not directly necessitate orders for ice packs or stool softeners. These specific orders are aimed at local pain and discomfort management, which are typically related to perineal trauma, not anesthesia administration.
Choice B rationale
Perineal ice packs reduce edema and pain from a fresh wound (laceration or episiotomy) through vasoconstriction. Sitz baths promote healing and comfort later. A stool softener prevents straining, which could disrupt sutures or increase pain. These interventions are directly indicated for a second-, third-, or fourth-degree perineal laceration or an episiotomy.
Choice C rationale
Gravida 2, para 2 simply describes the woman's obstetric history (two pregnancies, two births) and does not inherently suggest specific perineal trauma. While a multiparous woman may have had a similar injury before, the current orders are based on the current delivery's perineal status, not past history.
Choice D rationale
A vacuum-assisted birth is often associated with an increased risk of significant perineal trauma (lacerations and episiotomy) due to the forces applied or the need for a larger opening. Therefore, the orders for ice packs, sitz baths, and a stool softener are a consequence of the likely perineal injury sustained during this operative delivery. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
PPROM stands for Preterm Premature Rupture of Membranes, meaning the rupture occurs before 37 weeks of gestation (preterm) and before the onset of labor (premature). This patient is at 37 weeks, which is considered full term (or early term), and the rupture of membranes (SROM) occurred after the onset of contractions, which is termed rupture of membranes (ROM) or SROM.
Choice B rationale
PPROM is the rupture of the amniotic sac (bag of waters) occurring before 37 weeks of gestation (preterm) and before the onset of labor (premature). This patient is at 36 weeks (preterm, as the normal range is 37-42 weeks), and the membranes ruptured at 21: at home, suggesting it happened before the onset of active, regular uterine contractions that mark labor initiation.
Choice C rationale
This describes a possible urinary tract infection (UTI) or pyelonephritis (flank pain). While infection is a risk factor for PPROM and preterm labor, the symptoms described are not the definition of PPROM, which is a rupture of the membranes (often described as a gush or trickle of fluid) before 37 weeks gestation. The symptoms relate to maternal health, not specifically the membrane status.
Choice D rationale
This patient is at 39 weeks of gestation, which is considered full term. Even if the membranes ruptured before the onset of labor (PROM), it is not preterm rupture of membranes (PPROM). The term used for membrane rupture at or after 37 weeks is typically Premature Rupture of Membranes (PROM), or simply SROM if labor has started. —. ##
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale
Slapping an infant's hands and feet is an inappropriate and potentially harmful technique for waking a baby. This is a painful, aggressive, and disrespectful action that is physically abusive and may cause the infant to associate feeding with unpleasant stimuli. Gentle, non-painful stimulation is the correct approach to promote alertness without distress or injury, fostering a positive association with feeding.
Choice B rationale
Applying a cold towel to an infant's abdomen is an overly aggressive and inappropriate method that can cause distress and initiate cold stress, a significant concern in newborns due to their large surface area-to-volume ratio and limited subcutaneous fat for insulation. Cold stress can rapidly lead to increased oxygen and glucose consumption, potentially causing hypoglycemia and respiratory distress, making this method physiologically detrimental.
Choice C rationale
Unwrapping the infant is an appropriate, non-painful stimulation technique that slightly lowers the ambient temperature against the skin, providing a gentle thermal cue that promotes arousal and alertness. This minor, controlled temperature change is a tactile and thermal stimulus that is typically effective for transitioning a sleepy baby into a more alert state for successful initiation of breastfeeding.
Choice D rationale
Talking to the infant involves the use of auditory stimulation, a gentle and effective method to increase a newborn's level of arousal. The change in pitch and volume of a human voice, especially one familiar to the infant, helps to engage the baby's senses and move them from a deep sleep or drowsy state to one of quiet alertness, which is optimal for feeding.
Choice E rationale
Changing the diaper provides tactile and thermal stimulation as the baby is handled and unwrapped and may also expose them briefly to a cooler surface or air. This combination of gentle movement and temperature change serves as a strong arousal cue to increase alertness without causing distress, making it a highly effective and appropriate method to prepare a sleepy infant for a feeding session. —.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.