The nurse is caring for a postpartum patient who experienced a second-degree laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time?
Apply an ice pack to the perineum
Teach the woman to insert nothing into her rectum
Advise the woman to sit on a pillow
Advise the woman to use sitz bath after each void
The Correct Answer is A
A) Apply an ice pack to the perineum:
For a second-degree perineal laceration sustained during delivery, ice application is an important intervention within the first 24 hours to reduce swelling, pain, and inflammation in the perineal area. Ice packs help constrict blood vessels, decrease tissue edema, and provide analgesic effects. This intervention is most effective immediately after delivery and within the first 2-4 hours to help manage pain and swelling at the site of the laceration.
B) Teach the woman to insert nothing into her rectum:
While it is true that women with perineal lacerations should avoid rectal trauma or anything inserted into the rectum (e.g., rectal thermometers, suppositories) for a period of time, this is not the most urgent or immediate action for this patient. The primary concern at this point is managing the acute symptoms related to the laceration (e.g., swelling, pain), which is best managed with ice packs and other measures. Teaching about avoiding rectal insertion would be important later in the postpartum period.
C) Advise the woman to sit on a pillow:
While sitting on a pillow can reduce pressure on the perineum and help with comfort, it is not the most immediate intervention for this woman, especially in the first few hours postpartum. The priority should be addressing swelling and pain associated with the perineal laceration, which is best managed with ice, as it helps with the acute management of the injury.
D) Advise the woman to use sitz bath after each void:
A sitz bath can be helpful for perineal healing in the postpartum period, but it is typically recommended after the first 24 hours post-delivery, after the initial swelling has gone down. During the first few hours to days postpartum, ice packs are generally the preferred intervention to manage swelling and pain, while sitz baths are often advised later to promote comfort, healing, and circulation in the perineum.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Axillary temp of 96.9F (36.0 C) after 30 minutes of skin-to-skin contact with the mother:
A temperature of 96.9°F (36.0°C) is lower than the expected normal range for a newborn, which is typically between 97.7°F (36.5°C) and 99.5°F (37.5°C). However, after 30 minutes of skin-to-skin contact with the mother, the temperature is likely to increase as the infant benefits from the warmth of the mother's body. If the temperature does not rise or if it continues to decrease, further intervention would be necessary.
B) Respiratory rate of 58 during assessment at beginning of shift:
Newborns may have slightly irregular and rapid breathing patterns, especially right after birth, but this is not a cause for concern unless accompanied by signs of respiratory distress, such as retractions, flaring, or grunting.
C) Heart rate of 162 while crying vigorously after a diaper change:
It is not uncommon for a newborn to have an elevated heart rate when upset or crying. A heart rate of 162 while crying is expected and does not indicate a problem. Once the baby calms down, the heart rate will likely return to its baseline.
D) No void after 8 hours of life:
The absence of a urine output within the first 8 hours of life is concerning and requires immediate follow-up. Newborns typically void within the first 24 hours, and if there is no urine output by 8 hours, it could indicate a potential problem such as dehydration, urinary tract obstruction, or renal dysfunction. A healthcare provider should be notified promptly for further assessment and intervention.
Correct Answer is A
Explanation
A) Caput succedaneum present:
Caput succedaneum refers to the swelling of the soft tissues on the newborn's head, typically caused by the pressure exerted during vaginal delivery. This condition is often seen after a prolonged labor or in cases of vacuum-assisted delivery. It presents as a soft, fluid-filled swelling that crosses the suture lines, which distinguishes it from a cephalhematoma (a collection of blood). This swelling is usually benign and resolves within a few days after birth without intervention.
B) Severe molding present:
Molding refers to the shaping of the newborn's skull bones as they overlap to pass through the birth canal during delivery. It typically presents as elongated or asymmetric head shapes, particularly in the vertex presentation. Severe molding would not involve swelling of the soft tissues and would not cross the suture lines. This term is typically used to describe changes in the shape of the skull bones rather than soft tissue swelling.
C) Cephalhematoma present:
A cephalhematoma is a collection of blood between the newborn's skull and the periosteum (the membrane covering the bones). Unlike caput succedaneum, a cephalhematoma does not cross the suture lines because the blood is confined to the area overlying the affected bone. Cephalhematomas are typically the result of trauma during delivery, such as forceps or vacuum extraction. The swelling in a cephalhematoma is firmer and does not appear as soft or fluid-filled as caput succedaneum.
D) Fontanels soft and flat:
The fontanels are the soft spots on the baby’s head where the skull bones have not yet fused. The anterior fontanel is usually the most prominent, and the posterior fontanel is much smaller. While fontanels should be soft and flat in the early stages, this option doesn't describe the swelling or soft tissue findings as described in the question. The soft, fluid-filled swelling over the head would be more indicative of caput succedaneum rather than a normal fontanel finding.
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