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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

This is because epidural anesthesia can cause hypotension (low blood pressure) which can affect the placental blood flow and fetal oxygenation.

The nurse should monitor the patient’s blood pressure frequently and intervene if it drops below the baseline.

Choice A is wrong because assessing the patient’s urine for acetone is not relevant to the side effects of epidural anesthesia.Acetone in urine can indicate diabetic ketoacidosis, a complication of diabetes that occurs when the body breaks down fat for energy due to lack of insulin.

However, this is not related to epidural anesthesia.

Choice B is wrong because monitoring the patient’s deep tendon reflexes is not relevant to the side effects of epidural anesthesia.Deep tendon reflexes can be affected by magnesium sulfate, a medication used to prevent seizures in patients with preeclampsia (a condition characterized by high blood pressure and proteinuria in pregnancy).

However, this is not related to epidural anesthesia.

Choice C is wrong because assessing the patient’s pupillary accommodation is not relevant to the side effects of epidural anesthesia.

Pupillary accommodation is the ability of the eye to adjust its focus from distant to near objects.It can be impaired by drugs that affect the nervous system, such as opioids or anticholinergics.

A. “Have you had any shortness of breath?”. B. “Have you had any episodes of loss of consciousness?”. C. “Have you had any spotting?”. D. “Have you noticed any tenderness in your breasts?”.

Correct Answer is D

Explanation

The correct answer is choice D. “Have you noticed any tenderness in your breasts?”

Breast tenderness is one of the early signs of pregnancy that may occur as early as one to two weeks after conception.It is caused by hormonal changes that prepare the breasts for lactation.

Choice A is wrong because shortness of breath is not a sign of early pregnancy.It may occur later in pregnancy due to the growing uterus pressing on the diaphragm.

Choice B is wrong because episodes of loss of consciousness are not a sign of early pregnancy.They may indicate a serious condition such as anemia, dehydration, or hypoglycemia that requires medical attention.

Choice C is wrong because spotting is not a sign of early pregnancy.

It may be a sign of implantation bleeding, which occurs when the fertilized egg attaches to the lining of the uterus.However, implantation bleeding is usually much lighter and shorter than a normal period.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient who is 37 weeks pregnant and has gestational diabetes is admitted to the labor and delivery unit for induction. The patient is placed on an external fetal monitor and receives an epidural anesthesia.Which action should the nurse take to identify a potential side effect of the epidural?

Correct Answer is D

Explanation

A nurse is caring for a female client who suspects she is pregnant. Which question, if asked by the nurse, is consistent with signs of early pregnancy?

Correct Answer is D

Explanation

A nurse is caring for a patient being evaluated for sexually transmitted infection (STI).A negative rapid plasma reagin (RPR) indicates that a patient is probably not infected with which STI?

A nurse is caring for a client who has gestational diabetes and is scheduled for an amniocentesis at 37 weeks of gestation due to suspected fetal compromise. What is the nurse’s best response to the client’s question as to why the amniocentesis test is being done?

A patient who is 26 weeks pregnant has gestational diabetes and is to begin insulin management. When discussing the patient’s insulin needs, which information should the nurse include?

A nurse is caring for a newborn of a diabetic mother (IDM). What should the nurse monitor for during care of the newborn?

A nurse is caring for a 16-year-old primigravida who is in the last month of an uncomplicated pregnancy. Which measure is most appropriate to include in the patient’s plan of care?

The nurse prepares to counsel a 14-year-old patient who is 16 weeks pregnant regarding nutrition. Which action would be appropriate for the nurse to take first?

A patient who is 38 weeks pregnant is admitted to the hospital in active labor. On admission, the patient says, “For the past ten hours, I have been leaking small amounts of urine.” Which action should the nurse take initially?

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?