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What nursing intervention does the nurse include in the plan of care for a person with a perineal laceration infection?
- A. Demonstrate the use of a urinary catheter.
- B. Provide an abdominal binder.
- C. Encourage use of the peri-bottle for cleaning front to back.
- D. Discourage use of pain medications.
Correct Answer: C
Rationale: The correct answer is C because using a peri-bottle for cleaning front to back helps prevent introducing more bacteria into the infected perineal laceration. This method maintains proper hygiene, reduces the risk of further infection, and promotes healing. A urinary catheter (A) is not typically indicated for a perineal laceration infection. An abdominal binder (B) may provide support but does not directly address the infection. Discouraging pain medications (D) is not appropriate as pain management is important for patient comfort and healing.
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A client, 2 days postpartum from a spontaneous vaginal delivery, asks the nurse about postpartum exercises. Which of the following responses by the nurse is appropriate?
- A. You must wait to begin to perform exercises until after your six-week postpartum checkup.
- B. You may begin Kegel exercises today, but do not do any other exercises until the doctor tells you that it is safe.
- C. By next week you will be able to return to the exercise schedule you had during your prepregnancy.
- D. You can do some Kegel exercises today and then slowly increase your toning exercises over the next few weeks.
Correct Answer: D
Rationale: Kegel exercises can be started early postpartum to help strengthen pelvic floor muscles. Other exercises can be gradually increased after approval from the healthcare provider.
The nurse assesses the fundus and finds it to be boggy, elevated >2 fingerbreadths above the umbilicus, and deviated to one side. What is the common cause of this finding?
- A. uterine rupture
- B. full bladder
- C. perineal laceration
- D. hematoma
Correct Answer: B
Rationale: A full bladder can displace the uterus and prevent it from contracting properly leading to a boggy fundus.
The nurse works in a labor and delivery facility with new protocols for estimating postpartum blood loss. Which method for estimating blood loss is implemented in the delivery room?
- A. Ask the patient how many peripads she considered to be “soaked.”
- B. Collect blood in calibrated, under-buttocks drapes for vaginal birth.
- C. Place a basin at the foot of the delivery table to catch any blood.
- D. Rely on the primary health care provider’s estimate of blood loss.
Correct Answer: B
Rationale: Collecting blood in calibrated, under-buttocks drapes for vaginal birth and then weighing the drapes is the easiest way to estimate blood loss in the delivery room.
The nurse suspects that her postpartum client is experiencing hemorrhagic shock. Which observation indicates or would confirm this diagnosis?
- A. Absence of cyanosis in the buccal mucosa
- B. Cool, dry skin
- C. Calm mental status
- D. Urinary output of at least 30 ml/hr
Correct Answer: D
Rationale: The correct answer is D because a urinary output of at least 30 ml/hr indicates adequate perfusion and kidney function, which is crucial in managing hemorrhagic shock. Low urine output is a sign of poor perfusion and impending organ failure. Absence of cyanosis in the buccal mucosa (choice A) is not specific to hemorrhagic shock. Cool, dry skin (choice B) is a late sign of shock. A calm mental status (choice C) can be seen in the compensatory stage of shock.
A postpartum patient informs the nurse of a frequent urge and burning when attempting to urinate. The nurse reviews the patient’s medical record and associates which risk factors related to a possible urinary tract infection (UTI)? Select all that apply.
- A. Neonatal macrosomia
- B. Use of a vacuum extractor
- C. Poor oral fluid intake
- D. Urinary catheter during labor
Correct Answer: C
Rationale: The correct answer is C: Poor oral fluid intake. Postpartum patients are at increased risk for UTIs due to physiological changes and decreased fluid intake. Poor hydration can lead to concentrated urine, making it easier for bacteria to grow. Neonatal macrosomia (A) and use of a vacuum extractor (B) are not directly associated with UTIs. While a urinary catheter during labor (D) can increase the risk of UTIs, it is not the most relevant factor in this scenario compared to poor oral fluid intake.