Nokea
The postpartum client suffered a fourth-degree perineal laceration during her vaginal birth. Which interventions should the nurse add to the client’s plan of care? Select all that apply.
- A. Limit ambulation to bathroom privileges only.
- B. Decrease fluid intake to 1000 mL every 24 hours.
- C. Instruct the client on a high-fiber diet.
- D. Monitor the uterus for firmness every 2 hours.
- E. Give pm prescribed stool softeners in the am. and at h.s.
Correct Answer: C,E
Rationale: Activity should be increased, not decreased, to reduce the potential for constipation. Fluids should be increased, not decreased, to reduce the potential for dehydration and constipation. The client with a fourth-degree perineal laceration should be instructed to increase dietary fiber to help maintain bowel continence and decrease perineal trauma from constipation. A perineal laceration will not affect the condition of the uterus; there is no need to increase uterine monitoring. The client with a fourth-degree perineal laceration should be given a stool softener bid to help maintain bowel continence and decrease perineal trauma from constipation.
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The client, who delivered a 4200-g baby 4 hours ago, continues to have bright red, heavy vaginal bleeding. The nurse assesses the client’s fundus and finds it to be firm and midway between the symphysis pubis and umbilicus. What should the nurse do next?
- A. Continue to monitor the client’s bleeding and weigh the peripads.
- B. Call the client’s HCP and request an additional visual examination.
- C. Prepare to give oxytocin to stimulate uterine muscle contraction.
- D. Document the findings as normal with no interventions needed at that time.
Correct Answer: B
Rationale: Although the nurse would definitely need to continue to monitor the amount and quality of bleeding, additional intervention is also needed. The nurse should consider the possibility of a vaginal wall or cervical laceration, which could produce heavy, bright red bleeding. The HCP should be notified and asked to perform a visual exam of the vagina to assess for possible lacerations in need of repair. Preparing to administer oxytocin (Pitocin) would be appropriate if the source of bleeding was suspected to be uterine atony, but the uterus is firm and in the expected location. Documenting the findings without further intervention would lead to a failure to identify the source of increased bleeding resulting in possible client injury. Further assessments and interventions are needed.
Where can the nurse expect to palpate the fundus at this time?
- A. Just above the symphysis pubis
- B. Just below the xiphoid process
- C. Near the level of the umbilicus
- D. Just below the symphysis pubis
Correct Answer: C
Rationale: At 20 weeks' gestation, the fundus is typically palpated near the level of the umbilicus, reflecting uterine growth.
At this point in the client's pregnancy, which test is typically used to detect genetic disorders?
- A. Amniocentesis
- B. Chorionic villi sampling
- C. Rapid plasma reagin
- D. Ultrasound
Correct Answer: B
Rationale: Chorionic villi sampling is performed at 10-13 weeks to detect genetic disorders, suitable for a 10-week pregnancy.
During the first postpartum checkup, the nurse is assessing whether the client’s chloasma has diminished. At which anatomical location is the nurse performing the assessment?
- A. Perineum
- B. Abdomen
- C. Breasts
- D. Face
Correct Answer: D
Rationale: Chloasma does not appear on the perineum. Chloasma does not appear on the abdomen. Chloasma does not appear on the breasts. The nurse should be assessing the skin over the cheeks, nose, and forehead for chloasma.
The nurse explains that, in addition to increased blood volume, which other condition causes varicose veins during pregnancy?
- A. Impaired venous return
- B. Decreased cardiac output
- C. Altered center of gravity
- D. Impaired kidney function
Correct Answer: A
Rationale: Impaired venous return, due to the uterus compressing veins, causes varicose veins, compounded by increased blood volume.