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 tid, and a stool softener. What information is most closely correlated with these orders?

The woman had a vacuum-assisted birth.

The woman is a gravida 2, para 2.

The woman has an episiotomy.

The woman received epidural anesthesia.

Answer and Explanation

The Correct Answer is C

A. The woman had a vacuum-assisted birth. While vacuum-assisted births can cause perineal trauma, the specific orders for ice packs, sitz baths, and stool softeners are more directly related to an episiotomy, which involves a surgical incision that requires careful postpartum care.

B. The woman is a gravida 2, para 2. This information indicates the woman's obstetric history but does not directly correlate with the need for perineal ice packs, sitz baths, and stool softeners. These orders are more specific to perineal trauma or surgical intervention.

C. The woman has an episiotomy. An episiotomy involves a surgical cut made at the opening of the vagina during childbirth, which can cause significant perineal pain and swelling. The orders for perineal ice packs, sitz baths, and stool softeners are intended to manage pain, reduce swelling, and prevent constipation, which can be particularly uncomfortable with perineal stitches.

D. The woman received epidural anesthesia. While epidural anesthesia is a common pain management technique during labor, it does not necessitate the use of perineal ice packs, sitz baths, or stool softeners postpartum. These orders are more indicative of perineal trauma or surgical intervention such as an episiotomy.

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Correct Answer is B

Explanation

Choice A reason:

If the client reports frequent uterine contractions , it is not indicative of a distended bladder. Postpartum uterine contractions are normal and necessary to help the uterus return to its pre-pregnancy size.

Choice B reason:

The fundus (the top portion of the uterus being palpable to the right of the midline suggests a distended bladder. A full bladder can displace the uterus, causing the fundus to deviate from the midline.

Choice C reason:

Having less than 2.5 cm of rubra lochia on a perineal pad is related to the amount of vaginal discharge after birth and does not provide information about bladder distention.

Choice D reason:

The client's report of increased thirst may indicate dehydration or the body's response to fluid loss during childbirth but is not directly related to bladder distention.

A. Tonic neck reflex. B. Moro reflex. C. Startled reflex. D. Babinski reflex.

Correct Answer is A

Explanation

Choice A reason:

The tonic neck reflex, also called the fencing posture, occurs when a baby's head is turned to one side. The arm and leg on that side stretch out, while the opposite arm and leg bend up at the elbow. This reflex lasts until the baby is about 5 to 7 months old. This reflex matches the description of the question.

Choice B reason:

The Moro reflex, also called the startle reflex, is the baby's reaction to being startled. The cause is often a loud sound, a sudden movement, or even their own cry. As an adult, you may jump or gasp when you are startled. A baby will throw back their head, extend their arms and legs, cry, then pull their arms and legs back in. This reflex does not match the description of the question.

Choice C reason:

The startled reflex is not a distinct reflex in newborns. It is another name for the Moro reflex, which is explained.

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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 tid, and a stool softener. What information is most closely correlated with these orders?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

Correct Answer is B

Explanation

Which newborn reflex elicits the following reaction: Head turns to one side - the way the head is facing, the arm/leg is stretched out while the other is bent?

Correct Answer is A

Explanation

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A maternal indication for the use of vacuum extraction is

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