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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A) The vaccine is a live virus and may cause birth defects in the fetus:
The Rubella vaccine is a live attenuated virus, which means it contains a weakened form of the virus. Although this vaccine is safe for most adults, it can cause serious birth defects if a woman becomes pregnant within a 4-week period after receiving the vaccine. The live virus could potentially affect the developing fetus, causing congenital rubella syndrome (CRS), which can result in severe birth defects like heart defects, deafness, and cataracts. To prevent any risk to a future pregnancy, women are advised to wait at least 4 weeks after
vaccination before trying to conceive.

B) Tests to determine if the client developed immunity are not accurate for a month:
This is not accurate. While some tests for rubella immunity can be done soon after vaccination, the primary reason for delaying pregnancy is the live virus in the vaccine, not a delay in testing. The immune response to the vaccine typically develops within a few weeks, but the risk to a fetus comes from the live virus, not the testing process. The 4-week delay is to ensure that the virus has been cleared from the body before pregnancy is attempted.

C) She may have the virus and feel too sick to tolerate a pregnancy:
While the Rubella vaccine can cause mild side effects like fever, it does not typically cause significant illness that would prevent a woman from tolerating a pregnancy. The primary concern is the safety of the fetus, not the mother's symptoms, as any illness is generally mild and transient. The 4-week delay is to prevent potential harm to a fetus due to the live virus present in the vaccine.

D) Her body is not ready to nurture another pregnancy so quickly:
This rationale is not based on any medical guideline. There is no evidence to suggest that the body needs time to "recover" from the Rubella vaccine before becoming pregnant. The reason for the 4-week delay is to ensure that the live virus has been cleared from the body to avoid any risk to a potential pregnancy. The concern is not about the woman's ability to support another pregnancy, but about the potential for the live vaccine virus to harm a developing fetus.

A. Ask the patient to empty her bladder B. Notify the MD about an impending hemorrhage C. Assess blood pressure and pulse D. Evaluate lochia

Correct Answer is A

Explanation

A. Ask the patient to empty her bladder:
A boggy uterus that is displaced above and to the right of the umbilicus is often a sign of bladder distention. A full bladder can push the uterus out of its normal position, preventing it from contracting properly and leading to uterine atony. Asking the patient to empty her bladder is the most appropriate initial action, as it can help reposition the uterus and promote uterine contraction, reducing the risk of postpartum hemorrhage.

B. Notify the MD about an impending hemorrhage:
While a boggy, displaced uterus can be a sign of uterine atony and the risk of hemorrhage, the first action should be to address the likely cause—bladder distention. Emptying the bladder may resolve the issue and help the uterus contract. Notifying the healthcare provider may be necessary later if other complications arise, but it’s not the most immediate intervention in this situation.

C. Assess blood pressure and pulse:
Assessing vital signs, including blood pressure and pulse, is important for monitoring the patient’s overall condition, especially if there is suspicion of hemorrhage. However, this is a secondary action after addressing the immediate problem (bladder distention). The priority is to help the uterus contract and reposition it before worrying about potential hemorrhage.

D. Evaluate lochia:
Evaluating lochia is an important step in assessing the patient’s postpartum status, especially to monitor for excessive bleeding. However, the immediate concern in this case is the displaced uterus, which is most likely due to bladder distention. The most effective action would be to address the bladder fullness first. After addressing this, lochia should be assessed to monitor for bleeding.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A postpartum client is to receive the Rubella vaccine prior to discharge from the hospital. Why is she instructed to not become pregnant for 4 weeks after receiving this vaccine?

Correct Answer is A

Explanation

Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus?

Correct Answer is A

Explanation

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