During the postpartal admission assessment, the nurse notes that a patient’s perineum appears edematous and ecchymotic.
Based on this finding, which action should the nurse take?
Observe the patient for vaginal discharge of bright red blood.
Assess the patient’s vaginal tone.
Massage the patient’s perineum.
Apply petrolatum to the patient’s perineum.
The Correct Answer is D
The correct answer is choice D. Apply petrolatum to the patient’s perineum. This is because petrolatum can help soothe and protect the perineal area, which may be swollen, bruised, or have stitches after a vaginal delivery. Applying petrolatum can also prevent the pad from sticking to the wound and causing more pain.
Choice A is wrong because observing the patient for vaginal discharge of bright red blood is not a specific action for perineal care. Bright red blood may indicate postpartum hemorrhage, which requires immediate medical attention.
Choice B is wrong because assessing the patient’s vaginal tone is not a priority action for perineal care. Vaginal tone may be reduced after childbirth due to stretching of the pelvic floor muscles, but this can improve with time and exercises.
Choice C is wrong because massaging the patient’s perineum is not recommended for perineal care. Massaging the perineum may cause more trauma and discomfort to the area, especially if there are stitches or hemorrhoids. Massaging the fundus (the top of the uterus) may be done to help it contract and prevent bleeding, but this is different from massaging the perineum.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Syphilis.A negative rapid plasma reagin (RPR) test indicates that a patient is probably not infected with syphilis, a sexually transmitted infection (STI) caused by the bacterium Treponema pallidum.The RPR test works by detecting the nonspecific antibodies that your body produces while fighting the infection.
Choice A is wrong because herpes simplex II is a viral infection that causes genital herpes, and it is not detected by the RPR test.
Choice C is wrong because gonorrhea is a bacterial infection caused by Neisseria gonorrhoeae, and it is also not detected by the RPR test.
Choice D is wrong because condylomata are genital warts caused by human papillomavirus (HPV), and they are not detected by the RPR test either.
The RPR test is a screening test, and it can give false-positive results due to other conditions or infections.Therefore, a positive RPR test should always be confirmed by a more specific treponemal test, such as TPPA or FTA-ABS.The RPR test can also be used to monitor the treatment response of syphilis, as the antibody levels should decrease after effective antibiotic therapy.
Correct Answer is C
Explanation
This is because the patient is experiencing supine hypotension syndrome, which occurs when the weight of the gravid uterus compresses the inferior vena cava and reduces venous return and cardiac output. Turning the patient onto her side will relieve the pressure and improve blood flow.
Choice A is wrong because taking the patient’s blood pressure will not address the cause of her symptoms and may delay appropriate intervention.
Choice B is wrong because breathing into her cupped hands will not improve her circulation and may increase her carbon dioxide levels.
Choice D is wrong because elevating the patient’s legs will not relieve the compression of the inferior vena cava and may worsen her condition.Normal blood pressure for a pregnant woman is 110/70 to 120/80 mmHg.Normal heart rate for a pregnant woman is 60 to 90 beats per minute.Normal respiratory rate for a pregnant woman is 16 to 24 breaths per minute.
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