The nurse prepares a client at 41 weeks gestation for placement of cervical ripening medication followed by oxytocin. The client is not in labor. This plan of care represents:
Induction because the client is already dilated
Augmentation because the cervix is unripe
Induction because labor has not begun naturally
Augmentation because contractions will become stronger
The Correct Answer is C
A. Induction is not dependent on cervical dilation alone. Even if the client were dilated, the defining factor for induction is that labor has not started spontaneously. Therefore, this option is incorrect.
B. Augmentation refers to stimulating or enhancing labor that has already begun, often using oxytocin or other interventions. Cervical ripening is typically done before induction, so this is not augmentation.
C. Induction of labor is the process of initiating labor artificially in a client who is not in labor, often due to post-term pregnancy, medical complications, or other indications. In this scenario, the client is at 41 weeks gestation and labor has not begun naturally, and cervical ripening medication is being used to prepare the cervix for labor before administering oxytocin to stimulate contractions. This clearly represents labor induction.
D. Augmentation refers specifically to strengthening or regulating contractions in labor that has already started, not initiating labor in a client who is not in labor. Since this client is not in labor yet, augmentation does not apply.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Retained placental fragments typically cause a soft, boggy uterus and late postpartum hemorrhage rather than a steady trickle of bright red blood with a firm fundus immediately after delivery. This does not match the assessment findings described.
B. Perineal laceration is the most likely cause. When the uterus is firm and midline, it indicates that uterine atony is not the source of bleeding. A steady trickle of bright red blood from the vagina, despite a firm uterus, suggests bleeding from a laceration of the cervix, vagina, or perineum, which is common after vaginal delivery. This finding matches the clinical scenario.
C. Subinvolution refers to the delayed return of the uterus to pre-pregnancy size, often occurring weeks after delivery. It usually presents with prolonged lochial discharge rather than immediate postpartum bleeding with a firm uterus.
D. A hematoma is a collection of blood within the soft tissues of the perineum or vulva. It usually presents with localized swelling, pain, and sometimes vaginal pressure, rather than a continuous, visible trickle of bright red blood. The absence of a firm, localized swelling makes this less likely in this scenario.
Correct Answer is C
Explanation
A. Ice application does not decrease lochia. Lochia is the normal postpartum vaginal discharge consisting of blood, mucus, and uterine tissue. Its flow is regulated by uterine contractions and involution, not by external cooling. Ice has no impact on the volume, color, or duration of lochia.
B. Ice does not provide a painful effect; rather, it provides a pain-relieving or numbing effect by slowing nerve conduction in the area. While clients may feel temporary numbness, the purpose is analgesia, not inducing pain. The cold temperature can help reduce discomfort from perineal trauma, such as lacerations, episiotomies, or swelling.
C. Decreasing edema is the primary purpose of applying ice to the perineum after vaginal delivery. Ice causes vasoconstriction, which limits blood flow to the tissues, thereby reducing swelling and inflammation. Edema is common in the first 24 hours postpartum, especially after traumatic births, large babies, or prolonged pushing, and can contribute to pain and discomfort. Applying ice also helps minimize hematoma formation and can improve the client’s comfort during the early postpartum period. Ice therapy is typically recommended for 15–20 minutes at a time in the immediate postpartum period for optimal effectiveness.
D. Ice does not cleanse the perineum. Perineal hygiene is maintained through separate interventions such as peri-bottle rinsing, sitz baths, or gentle cleansing with warm water. Ice therapy only addresses swelling and discomfort, not infection control or cleanliness.
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