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 C
Explanation
The correct answer is choice C. The woman’s temperature will increase when she is ovulating.This is because ovulation is triggered by a surge of luteinizing hormone (LH), which also causes a slight rise in basal body temperature (BBT).By measuring her BBT every morning before getting out of bed, the woman can detect this subtle change and identify her fertile window.
Choice A is wrong because ovulation typically occurs around 14 days before the next menstrual period, not seven days after the previous one.
The length of the menstrual cycle can vary from woman to woman, so counting days is not a reliable method of predicting ovulation.
Choice B is wrong because cervical mucus will appear clear, slippery and stretchy when the woman is ovulating, not tacky and cloudy.
This type of mucus helps sperm swim and survive in the reproductive tract.
The woman can check her cervical mucus by wiping with toilet paper or inserting a finger into her vagina.
Choice D is wrong because abdominal massage of the ovaries will not stimulate ovulation, and may even cause harm by injuring the delicate tissues or introducing infection.
Correct Answer is D
Explanation
The correct answer is choice D: To prevent her from having convulsions.Magnesium sulfate is a mineral that reduces seizure risks in women with preeclampsia, a condition of high blood pressure and protein in the urine during pregnancy.Magnesium sulfate can lower the cerebral perfusion pressure and prevent convulsions.However, magnesium sulfate does not affect the neonatal outcomes and can cause side effects such as respiratory depression.
Choice A is wrong because magnesium sulfate does not decrease blood pressure.It is used along with medications that help reduce blood pressure.
Choice B is wrong because magnesium sulfate does not decrease tidal volume.It can cause respiratory depression if the serum level is too high.
Choice C is wrong because magnesium sulfate does not prevent dehydration.It can cause fluid retention and pulmonary edema if given in excess.
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