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 E

Explanation

A) Bulb syringe in crib:
While a bulb syringe can be useful for clearing the infant’s airway in case of respiratory distress, keeping it in the crib is not an optimal safety practice. The syringe should be readily available but not within reach of the infant, as it could be a choking hazard if mishandled. Ideally, it should be stored in an easily accessible area but not within the crib.

B) Secure hugs tag on and alarms activated:
Ensuring that the infant has a security tag (often referred to as a "Hugs" tag) that is properly placed and that alarms are activated is an important safety measure to prevent infant abductions. Hospitals typically use electronic security systems that alert staff if the infant is removed from the designated area without proper authorization. This intervention is essential for maintaining safety in the hospital setting.

C) ID bands match with mom's ID bands:
It is critical that the infant's ID band matches the mother's ID band. This helps prevent any mix-up or baby swap and ensures that the infant is properly identified at all times. Regular checks should be made to verify that the bands match and remain secure throughout the hospital stay.

D) Infant on their back to sleep:
Placing the infant on their back to sleep is a key guideline for reducing the risk of Sudden Infant Death Syndrome (SIDS). This position has been proven to be the safest for infants and is a crucial practice for their well-being. Educating parents and caregivers about safe sleep practices is vital for infant safety.

E) All of the above:
All of these practices are part of a comprehensive safety plan for the infant. Ensuring that the infant is safely secured with proper identification, preventing any risk of abduction, promoting safe sleep practices, and ensuring that airway equipment is available are all essential measures in maintaining the safety of the newborn. Therefore, the correct response is "All of the above."

A. The urethra, bladder and urinary meatus is edematous B. She has decreased sensitivity to fluid pressures after a vaginal birth C. At 12 hours postpartum she will begin diuresing D. There is no cause for concern as long as the patient urinates once shift E. A full bladder can lead to postpartum hemorrhage

Correct Answer is ["A","B","C","E"]

Explanation

A) The urethra, bladder, and urinary meatus are edematous:
Postpartum women often experience edema in the urethra, bladder, and urinary meatus due to the pressure exerted during delivery. This swelling can make it difficult for the woman to feel the urge to urinate, even when her bladder is full. Encouraging her to urinate every 2 hours helps prevent overdistension of the bladder, which can lead to urinary retention and other complications.

B) She has decreased sensitivity to fluid pressures after a vaginal birth:
After childbirth, especially a vaginal birth, the pelvic floor and surrounding tissues can be numb or less sensitive due to trauma, swelling, and the effects of anesthesia. This decreased sensitivity makes it harder for the woman to sense when she needs to urinate. Encouraging regular voiding even without the urge helps to prevent urinary retention, which is common in the immediate postpartum period.

C) At 12 hours postpartum, she will begin diuresing:
Diuresis, the process of excreting excess fluid retained during pregnancy, typically begins within 12 hours postpartum. This increased urine output can make it even more important for the mother to void regularly to prevent urinary retention. If the bladder is not emptied regularly, it can lead to discomfort and increase the risk of complications like bladder distention or infection.

D) There is no cause for concern as long as the patient urinates once per shift:
This is not true. A postpartum woman should void more frequently than once per shift (which is about every 8 hours). Urinating only once every shift can lead to urinary retention, bladder overdistension, and possible infection. The recommendation to urinate every 2 hours helps ensure proper bladder emptying and reduces the risk of complications.

E) A full bladder can lead to postpartum hemorrhage:
A full bladder can indeed contribute to postpartum hemorrhage (PPH). An overdistended bladder can displace the uterus, preventing it from contracting effectively after delivery. This can increase the risk of excessive bleeding. Regular voiding helps prevent bladder distention and supports uterine contraction, thereby reducing the risk of hemorrhage.

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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

You know that infant safety is important so which of the following should be in place to maintain infant safety:

Correct Answer is E

Explanation

Correct Answer is ["A","B","C","E"]

Explanation

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