When caring for a woman who just gave birth, what would the nurse educate the client in preventing postpartum complications?
Change sanitary pad only when completely saturated
Change sanitary pad 2 times per day
Cleanse from the periurethral to the perineal area
Remind her to vigorously wipe to remove excess blood
The Correct Answer is C
Choice A reason: Changing sanitary pads only when completely saturated is unsafe. Saturated pads increase the risk of infection because bacteria thrive in moist environments. Additionally, waiting until pads are fully soaked can delay recognition of excessive bleeding or postpartum hemorrhage.
Choice B reason: Changing sanitary pads only twice per day is inadequate. Postpartum women should change pads frequently, at least every few hours, to maintain hygiene and reduce infection risk. This practice also allows monitoring of lochia flow and early detection of abnormal bleeding.
Choice C reason: Cleansing from the periurethral area to the perineal area is the correct technique. This front-to-back cleansing prevents the transfer of bacteria from the rectal area to the urethra and vagina, reducing the risk of urinary tract infections and endometritis. Proper perineal hygiene is essential in preventing postpartum complications.
Choice D reason: Vigorous wiping is contraindicated. It can cause trauma to the perineum, especially if there are lacerations, episiotomy sites, or hemorrhoids. Gentle cleansing is recommended to avoid irritation and promote healing.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Intermittent fetal heart auscultation is appropriate when contractions are infrequent and the fetal heart rate is reassuring. It allows monitoring without continuous electronic fetal monitoring, especially in low-risk cases.
Choice B reason: Nipple stimulation is a natural method to promote uterine contractions by stimulating endogenous oxytocin release. However, in this case, contractions are already present, and nipple stimulation is not contraindicated.
Choice C reason: Administration of IV fluids is safe and often necessary to maintain hydration, support uteroplacental perfusion, and prevent maternal hypotension.
Choice D reason: Vaginal examinations every hour are contraindicated because the client has had ruptured membranes for 18 hours. Frequent vaginal exams increase the risk of ascending infection (chorioamnionitis). Vaginal exams should be minimized and performed only when clinically indicated.
Correct Answer is D
Explanation
Choice A reason: An increase in blood pressure is not a direct indicator of oxytocin’s effectiveness. Blood pressure changes may occur due to fluid shifts or vasoconstriction, but they do not confirm control of hemorrhage.
Choice B reason: An increase in lochia rubra would actually suggest worsening bleeding rather than improvement. Oxytocin should reduce blood loss by contracting the uterus, not increase it.
Choice C reason: Relief of afterpains is subjective and not a reliable measure of oxytocin’s effectiveness. Oxytocin often increases afterpains due to uterine contractions, so this is not a valid indicator.
Choice D reason: A firm uterus on palpation is the best indicator of oxytocin effectiveness. Oxytocin stimulates uterine smooth muscle contraction, which compresses blood vessels at the placental site, reducing hemorrhage. A firm uterus means bleeding is controlled.
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