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A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?
- A. Apply a moist, warm compress to the perineum.
- B. Provide the client with a cool sitz bath.
- C. Administer methylergonovine 0.2 mg IM.
- D. Apply povidone-iodine to the client’s perineum after she voids.
Correct Answer: A
Rationale: The correct answer is A: Apply a moist, warm compress to the perineum. This action helps to promote healing and reduce discomfort for the client with a fourth-degree perineal laceration. Warmth can increase blood flow to the area, aiding in the healing process. Moisture can also help with wound healing and provide comfort.
Choice B is incorrect as a cool sitz bath may not be suitable for a fourth-degree laceration as it can cause vasoconstriction and slow down the healing process. Choice C, administering methylergonovine, is not indicated for perineal lacerations. Choice D, applying povidone-iodine after voiding, can be irritating to the wound and delay healing.
In summary, applying a warm, moist compress is the best option to promote healing and comfort for the client with a fourth-degree perineal laceration.
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Which of the following hormones is responsible for maintaining the uterine lining during pregnancy?
- A. Progesterone
- B. Estrogen
- C. Prolactin
- D. Oxytocin
Correct Answer: A
Rationale: Progesterone is responsible for maintaining the uterine lining during pregnancy, supporting the developing fetus.
The nurse is teaching the client about postpartum depression. The nurse should encourage the client to----------------- and ----------------- to help prevent postpartum depression.
- A. Engage in regular physical activity
- B. Maintain a strong support system
- C. Get adequate rest and sleep
- D. Eat a well-balanced diet
Correct Answer:
Rationale: The nurse should encourage the client to:Engage in regular physical activity – Exercise can help boost mood, reduce stress, and improve overall well-being, which may help prevent postpartum depression. Maintain a strong support system – Connecting with family, friends, or support groups can provide motional support, reduce feelings of isolation, and help manage postpartum stress.
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Monitor blood glucose level every hr.
- B. Place the infant on his back with legs extended.
- C. Initiate seizure precautions.
- D. Provide a stimulating environment.
Correct Answer: C
Rationale: The correct answer is C: Initiate seizure precautions. The infant with neonatal abstinence syndrome is at risk for seizures due to drug withdrawal. By initiating seizure precautions, the nurse can ensure the safety of the infant by implementing measures such as padding the crib, having emergency medications readily available, and closely monitoring for any signs of seizure activity.
Choice A is incorrect because monitoring blood glucose levels every hour is not typically indicated for neonatal abstinence syndrome. Choice B is incorrect as placing the infant on his back with legs extended does not address the risk of seizures. Choice D is incorrect as providing a stimulating environment can exacerbate the symptoms of withdrawal.
Which of the following is a potential indication for induction of labor?
- A. Preeclampsia
- B. Gestational diabetes
- C. Fetal macrosomia
- D. All of the above
Correct Answer: A
Rationale: Preeclampsia is a common indication for the induction of labor.
A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identity as a manifestation of Increased risk for child abuse?
- A. I want to meet other parents to see if they are going through the same things.
- B. I try to respond to the baby quickly so she doesn't cry very long.
- C. I think the baby should be sleeping through the night by now.
- D. I have several friends who come by to help out with the baby.
Correct Answer: C
Rationale: Expecting a newborn to sleep through the night is unrealistic and may indicate frustration or lack of understanding, which are risk factors for child abuse. Other statements reflect normal parental concerns or support systems.