Question

Which nursing interventions promote comfort and healing after perineal laceration? (Select all that apply.)

Answer 1

Correct Answers:

Provide sitz baths after the first 24 hours.
Apply ice packs for the first 24 hours.
Teach perineal hygiene (peri-battle, front-to-back cleansing).
Offer prescribed analgesics and stool softeners.

Rationale :

💠 Provide sitz baths after the first 24 hours

💠 Warm sitz baths improve blood circulation to the perineal tissues, delivering oxygen and nutrients that accelerate wound healing.

💠 The gentle heat from the water helps soothe soreness, reduce inflammation, and ease discomfort caused by perineal trauma.

💠 It also promotes muscle relaxation of the perineum and surrounding tissues, enhancing the mother’s comfort.

💠 Starting sitz baths after the first 24 hours prevents bleeding complications that could occur if applied too soon after delivery.

💠 This routine supports both comfort and infection control, encouraging faster recovery.

🌿 Apply ice packs for the first 24 hours

🌿 Cold therapy causes vasoconstriction, which limits tissue swelling and minimizes pain immediately postpartum.

🌿 Applying ice packs for short intervals (15–20 minutes) numbs nerve endings and provides effective pain relief.

🌿 It also helps reduce hematoma formation by controlling local bleeding and inflammation in the sutured area.

🌿 After 24 hours, the nurse should transition to warm compresses or sitz baths to promote healing rather than continued vasoconstriction.

🌿 Using ice early enhances comfort and reduces edema, setting the stage for smooth tissue repair.

🌸 Teach perineal hygiene (peri-bottle, front-to-back cleansing)

🌸 Proper perineal care prevents the introduction of pathogenic bacteria that can delay healing or cause infection.

🌸 Using a peri-bottle with warm water after urination or bowel movements keeps the wound clean without irritating sutures.

🌸 Front-to-back cleansing avoids transferring fecal bacteria toward the perineum, maintaining aseptic hygiene.

🌸 The nurse should emphasize gentle pat drying rather than wiping to prevent disrupting sutures.

🌸 Teaching effective hygiene promotes self-care, comfort, and faster healing of perineal tissues.

💊 Offer prescribed analgesics and stool softeners

💊 Analgesics relieve postpartum pain, allowing the client to ambulate and rest comfortably, which aids tissue recovery.

💊 Stool softeners prevent constipation and reduce straining during defecation, which could stress or tear sutures.

💊 Preventing perineal pressure helps avoid wound dehiscence and promotes proper healing alignment of the laceration.

💊 This combination also reduces anxiety and fear associated with pain during bowel movements.

💊 Adequate pain control and bowel management are key to enhancing comfort and preventing complications in perineal repair.

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Answer 2

Correct Answers:

Objective

Rationale :

💠 Goodell’s sign refers to the softening of the cervix that occurs in early pregnancy due to increased vascularity and edema of the cervical tissue.

💠 It is observed by the examiner during a pelvic assessment, making it an objective finding.

💠 Objective signs are those that can be measured, seen, or palpated by the healthcare provider, unlike subjective signs, which are reported by the client.

💠 Recognizing this sign helps confirm probable signs of pregnancy, which are strong indicators but not definitive proof.

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Answer 3

Correct Answers:

Gynecoid

Rationale :

🌷 The gynecoid pelvis is considered the ideal pelvic shape for vaginal birth because it provides the widest pelvic diameters and round inlet that allows optimal fetal passage.

🌷 This pelvic type promotes efficient fetal descent and rotation during labor, reducing the likelihood of prolonged labor or operative delivery.

🌷 Its spacious dimensions allow equal anteroposterior and transverse diameters, supporting smooth delivery of the fetal head.

🌷 Other types such as android, anthropoid, and platypelloid have narrower or irregular inlets, which can make labor more difficult or require cesarean birth.

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Answer 4

Correct Answers:

Assist the client to void and reassess the uterus

Rationale :

🌼 A firm fundus displaced to the right commonly indicates a distended bladder that is pushing the uterus out of its midline position.

🌼 A full bladder can interfere with uterine contraction, increasing the risk of postpartum hemorrhage.

🌼 The nurse should first assist the client to void to allow the uterus to return to the midline and maintain firm tone.

🌼 After voiding, reassessing the fundus ensures proper uterine involution and confirms that the bladder was the cause of the deviation.

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Answer 5

Correct Answers:

Increase pelvic diameters and aid fetal descent

Rationale :

🌿 Upright or squatting positions use gravity to promote fetal descent through the birth canal.

🌿 These positions expand the pelvic outlet, providing more space for the fetal head to rotate and descend.

🌿 They also enhance uterine efficiency, improving contractions and facilitating shorter second-stage labor.

🌿 Encouraging mobility and upright posture can reduce the need for instrumental delivery and improve maternal pushing effectiveness.

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Answer 6

Correct Answers:

I will wear a supportive bra continuously."

Rationale :

💎 A supportive, well-fitted bra helps minimize breast stimulation, which reduces prolactin release and suppresses milk production.

💎 Continuous support prevents discomfort caused by engorgement and leaking.

💎 The client should avoid warm compresses or breast massage, as these stimulate milk flow.

💎 Additional measures include avoiding nipple stimulation and using cold packs for comfort if engorgement occurs.

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Answer 7

Correct Answers:

Order a serum hCG test

Rationale :

🔶 The serum human chorionic gonadotropin (hCG) test is the most accurate and early indicator of pregnancy.

🔶 hCG is produced by the trophoblastic cells of the developing embryo and can be detected as early as 7–9 days after conception.

🔶 Blood tests provide quantitative results, confirming pregnancy earlier than urine tests.

🔶 Physical signs such as breast tenderness or missed menses are presumptive signs, not diagnostic proof.

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Answer 8

Correct Answers:

A patient 24 hours postpartum with stable vitals and needs perineal care

Rationale :

🔷 A certified nursing assistant (CNA) can provide routine, stable care such as hygiene, comfort, and basic assistance.

🔷 Clients with stable vital signs and predictable outcomes are appropriate for delegation to unlicensed personnel.

🔷 The CNA can perform perineal care, measure intake/output, and report abnormal findings to the nurse.

🔷 Clients with complications or who require teaching, assessment, or medication remain the nurse’s responsibility.

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Answer 9

Correct Answers:

It promotes circulation, reduces thromboembolism risk, and aids bowel function.

Rationale :

🌺 Early ambulation enhances venous return, reducing the risk of deep vein thrombosis (DVT) due to postpartum hypercoagulability.

🌺 It also promotes intestinal motility, helping prevent constipation and abdominal distention.

🌺 Mobilization encourages uterine involution, as upright posture aids drainage of lochia.

🌺 It contributes to overall recovery, reducing pain and improving respiratory and musculoskeletal function.

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Answer 10

Correct Answers:

Assess uterine tone and location.
Inspect the placenta and membranes for completeness.
Monitor vaginal bleeding for amount and character.

Rationale :

💎 Assess uterine tone and location

💎 After placental expulsion, the uterus must remain firm, midline, and at or below the umbilicus to prevent postpartum hemorrhage. A boggy or soft uterus indicates uterine atony, a leading cause of postpartum bleeding.

💎 Palpating the fundus allows the nurse to determine if it is well-contracted, confirming adequate myometrial contraction and effective closure of uterine blood vessels at the placental site.

💎 If the uterus is deviated or relaxed, the nurse must intervene immediately — usually by assisting the client to empty the bladder or performing gentle fundal massage to restore firmness.

💎 Consistent assessment ensures early recognition of complications and promotes safe uterine involution, a critical postpartum process for healing and hemostasis.

🌷 Inspect the placenta and membranes for completeness

🌷 Thorough inspection of the placenta and membranes is vital to verify that no fragments remain inside the uterus, as retained tissue can prevent proper contraction.

🌷 The placenta should appear intact with a smooth maternal surface and complete membranes; missing cotyledons or torn membranes suggest possible retained placental fragments.

🌷 Retained tissue may cause persistent bleeding, uterine subinvolution, or infection, which can endanger the client’s recovery.

🌷 Prompt recognition of an incomplete placenta allows the provider to perform manual removal or uterine exploration before the client develops hemorrhage or endometritis.

🌷 This assessment is essential for confirming complete placental separation and ensuring the uterus can contract normally to maintain hemostasis.

🌼 Monitor vaginal bleeding for amount and character

🌼 After placental delivery, it is essential to evaluate lochia—the vaginal discharge that reflects uterine healing and involution.

🌼 The normal pattern progresses from lochia rubra (bright red) in the first few days to serosa and alba in subsequent stages.

🌼 The nurse must observe for excessive bleeding, clots, or foul odor, which could indicate uterine atony, retained fragments, or infection.

🌼 Quantifying blood loss and documenting the color and consistency of lochia allows early detection of postpartum hemorrhage, one of the leading causes of maternal morbidity.

🌼 Frequent assessment ensures prompt intervention, such as fundal massage or administration of uterotonic medications, to maintain client safety and recovery.

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NURS226 FALL 2025 BXB EXAM 2 (1)

No.

1 :
Which nursing interventions promote comfort and healing after perineal laceration? (Select all that apply.)

2 :
During a prenatal exam, the nurse notes a softening of the cervix (Goodell's sign). This finding is;

3 :
Which pelvic type is most favorable for vaginal delivery?

4 :
On postpartum day 1, a client has a firm fundus deviated to the right and reports bladder fullness. Which is the best action?

5 :
The nurse encourages upright or squatting positions during the second stage of labor because these positions:

6 :
A nurse is providing teaching to a postpartum client about lactation suppression. Which statement indicates understanding?

7 :
A nurse is assessing a woman who reports nausea, breast tenderness, and missed periods. Which action best confirms pregnancy?

8 :
Which postpartum client is appropriate for an CNA assignment?

9 :
Why is early ambulation recommended for postpartum clients?

10 :
After the placenta delivers, which nursing assessments are essential to confirm complete separation and minimize complications? (Select all that apply.)

💎 Assess uterine tone and location

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NURS226 FALL 2025 BXB EXAM 2 (1)

No.

1 : Which nursing interventions promote comfort and healing after perineal laceration? (Select all that apply.)

2 : During a prenatal exam, the nurse notes a softening of the cervix (Goodell's sign). This finding is;

3 : Which pelvic type is most favorable for vaginal delivery?

4 : On postpartum day 1, a client has a firm fundus deviated to the right and reports bladder fullness. Which is the best action?

5 : The nurse encourages upright or squatting positions during the second stage of labor because these positions:

6 : A nurse is providing teaching to a postpartum client about lactation suppression. Which statement indicates understanding?

7 : A nurse is assessing a woman who reports nausea, breast tenderness, and missed periods. Which action best confirms pregnancy?

8 : Which postpartum client is appropriate for an CNA assignment?

9 : Why is early ambulation recommended for postpartum clients?

10 : After the placenta delivers, which nursing assessments are essential to confirm complete separation and minimize complications? (Select all that apply.)

💎 Assess uterine tone and location

1 :
Which nursing interventions promote comfort and healing after perineal laceration? (Select all that apply.)

2 :
During a prenatal exam, the nurse notes a softening of the cervix (Goodell's sign). This finding is;

3 :
Which pelvic type is most favorable for vaginal delivery?

4 :
On postpartum day 1, a client has a firm fundus deviated to the right and reports bladder fullness. Which is the best action?

5 :
The nurse encourages upright or squatting positions during the second stage of labor because these positions:

6 :
A nurse is providing teaching to a postpartum client about lactation suppression. Which statement indicates understanding?

7 :
A nurse is assessing a woman who reports nausea, breast tenderness, and missed periods. Which action best confirms pregnancy?

8 :
Which postpartum client is appropriate for an CNA assignment?

9 :
Why is early ambulation recommended for postpartum clients?

10 :
After the placenta delivers, which nursing assessments are essential to confirm complete separation and minimize complications? (Select all that apply.)