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A nurse is taking care of a G2P2 woman with a third-degree perineal tear during the fourth stage of labor. The nurse should include which intervention in the plan of care during her 12-hour shift?
- A. Assess vital signs every 4 hours.
- B. Keep patient NPO for first 12 hours.
- C. Catheterize patient prior to first ambulation.
- D. Prepare ice pack for application to perineal area.
Correct Answer: D
Rationale: The correct answer is D: Prepare ice pack for application to perineal area. This intervention is crucial for managing pain and reducing swelling in the perineal area post third-degree tear. Ice packs help vasoconstriction, decreasing blood flow and minimizing inflammation. It also provides comfort to the patient.
A: Assess vital signs every 4 hours - This is important but not the priority in this situation. Monitoring vital signs is essential, but immediate comfort measures should be prioritized for the patient with a perineal tear.
B: Keep patient NPO for first 12 hours - There is no indication to keep the patient NPO for 12 hours. Adequate hydration and nutrition are important for postpartum recovery.
C: Catheterize patient prior to first ambulation - Catheterization may not be necessary unless there are specific indications. It is not a routine intervention for a perineal tear during the fourth stage of labor.
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The nurse on a postpartum unit is acutely aware that cultural influences impact the patient's process of 'becoming a mother.' For which isn't a cultural influence does the nurse assess?
- A. What amount of time the mother spends in each phase
- B. Differences in the mother's expectation related to ability to rest
- C. How the mother physically recovers from labor and delivery
- D. Mother's involvement in decision making for the first few months
Correct Answer: C
Rationale: The correct answer is C because how a mother physically recovers from labor and delivery is primarily influenced by biological and physiological factors rather than cultural influences. The mother's physical recovery is guided by medical interventions, individual health conditions, and postpartum care practices. On the other hand, choices A, B, and D are all influenced by cultural factors. Choice A pertains to cultural variations in rituals or customs related to the duration of each phase of becoming a mother. Choice B involves cultural beliefs around postpartum rest and support systems. Choice D addresses cultural norms regarding maternal autonomy and decision-making in the early stages of motherhood.
A postpartum patient comes to the clinic for her 6-week postpartum checkup. When assessing the patient's cervix, how should the nurse expect the cervix to appear?
- A. Noticeable small lacerations
- B. Approximately 3 cm dilated
- C. Symmetrically round external os
- D. Firm and thick
Correct Answer: C
Rationale: The correct answer is C: Symmetrically round external os. At 6 weeks postpartum, the cervix should have healed and returned to its pre-pregnancy state. The external os should appear symmetrically round, indicating proper healing and involution. A: Noticeable small lacerations would indicate incomplete healing. B: Approximately 3 cm dilated is not expected in a postpartum patient. D: Firm and thick would not be typical findings at 6 weeks postpartum.
The nurse is providing education to a postpartum woman about exercises to strengthen the pelvis musculature. Which instruction should be included?
- A. "Ambulate three times a day."
- B. "Perform Kegel exercises."
- C. "Enroll in an aerobics class after discharge."
- D. "Do passive range-of-motion exercises while lying in bed."
Correct Answer: B
Rationale: The correct answer is B: "Perform Kegel exercises." Kegel exercises strengthen the pelvic floor muscles, which can help prevent urinary incontinence and improve pelvic organ support. Ambulating (choice A) is important for overall mobility but does not specifically target the pelvic muscles. Enrolling in an aerobics class (choice C) focuses on cardiovascular fitness and may not specifically strengthen the pelvis. Doing passive range-of-motion exercises (choice D) does not actively engage and strengthen the pelvic muscles. Kegel exercises are the most appropriate choice as they directly target the pelvic musculature to improve strength and function.
The nurse is aware that some parenting skills are acquired through the process of intentional learning. Which activity does the nurse associate with intentional learning?
- A. The couple observes other individuals who are mothers and fathers.
- B. The couple attends hospital classes addressing newborn and infant care.
- C. The couple discusses with each other how they were parented.
- D. The couple watches media containing parenting roles.
Correct Answer: B
Rationale: The correct answer is B: The couple attends hospital classes addressing newborn and infant care. This is associated with intentional learning as it involves actively seeking out structured education on parenting skills. Attending classes allows the couple to acquire knowledge and skills related to newborn and infant care in a deliberate and purposeful manner.
Incorrect choices:
A: Observing other individuals who are mothers and fathers may provide some insights, but it is more passive and may not involve structured learning.
C: Discussing how they were parented is reflective but may not necessarily involve acquiring new parenting skills through intentional learning.
D: Watching media containing parenting roles is passive and may not provide the same level of structured education as attending classes specifically addressing newborn and infant care.
A nurse is taking care of a G2P2 woman with a third-degree perineal tear during the fourth stage of labor. The nurse should include which intervention in the plan of care during her 12-hour shift?
- A. Assess vital signs every 4 hours.
- B. Keep patient NPO for first 12 hours.
- C. Catheterize patient prior to first ambulation.
- D. Prepare ice pack for application to perineal area.
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Ice pack application reduces swelling and provides comfort to the perineal tear.
2. Ice packs help to decrease pain and promote healing in the perineal area.
3. Ice packs are a non-invasive and non-pharmacological method of pain relief.
4. Ice packs can be safely used without interfering with the wound healing process.
Summary of Incorrect Choices:
A: Assessing vital signs every 4 hours is important but not specific to managing perineal tear pain.
B: Keeping the patient NPO is not necessary for perineal tear management unless indicated for other reasons.
C: Catheterization prior to ambulation is not directly related to perineal tear care and may not be necessary during the fourth stage of labor.