Nokea
What nursing care should be provided to a woman with a third-degree laceration immediately after delivery?
- A. Warm compresses to the perineum
- B. Cold pack to the perineum
- C. Warm sitz bath
- D. Elevation of hips to prevent edema
Correct Answer: B
Rationale: Ice is applied to the perineum to reduce bruising and edema.
You may also like to solve these questions
How would the nurse position the woman to prevent compression of a prolapsed cord?
- A. On her right side with knees flexed
- B. On her left side with a pillow placed between her legs
- C. On her back with her head lower than the rest of her body
- D. Supine with her legs elevated and bent at the knee
Correct Answer: C
Rationale: The Trendelenburg's (head down) position displaces the fetus upward to stop compression of the prolapsed cord.
What will the nurse include in the educational plan?
- A. Onset is slow.
- B. Duration is short.
- C. Administration is by mouth.
- D. No known side effects.
- E. It is not the same drug as sufentanil.
Correct Answer: B,E
Rationale: Fentanyl has a rapid onset and short duration of action. Fentanyl, sufentanil, and alfentanil are distinct drugs. Fentanyl can cause respiratory depression but less than meperidine and is not administered by mouth.
What does the nurse explain is used to soften the cervix with a 'cervical ripening' agent?
- A. Prostaglandin gel insertion
- B. Intravenous oxytocin
- C. Warm saline douches
- D. Nipple stimulation
Correct Answer: A
Rationale: Prostaglandin gel is inserted in the cervix and the woman remains in bed for 1 to 2 hours, being monitored for uterine contractions.
What nursing assessment should be reported immediately after an amniotomy?
- A. Fetal heart rate is regular at 154 beats/minute.
- B. Amniotic fluid is clear with flecks of vernix.
- C. Amniotic fluid is watery and pale green.
- D. Maternal temperature is 37.8?°C.
Correct Answer: C
Rationale: Amniotic fluid should be clear. Green fluid indicates the fetus has passed meconium, which is associated with fetal compromise.
What is the most appropriate nursing diagnosis?
- A. Anxiety related to the development of postpartum complications
- B. Ineffective individual coping related to unfamiliarity with procedures
- C. Risk for ineffective parenting related to emergency cesarean section
- D. Grieving related to loss of expected birth experience
Correct Answer: D
Rationale: Women who have cesarean births usually need greater support than those who have vaginal births. They may feel grief, guilt, or anger, because the expected course of birth did not occur.