Author Question: The patient delivered vaginally 2 hours ago after receiving an epidural analgesia. She has a slight ... (Read 104 times)

Davideckstein7 · **on:** Jun 27, 2018

The patient delivered vaginally 2 hours ago after receiving an epidural analgesia. She has a slight tingling sensation in both lower extremities, but normal movement. She sustained a second-degree perineal laceration.

Her perineum is edematous and ecchymotic. What should the nurse include in the plan of care for this patient? 1. Assist the patient to the bathroom in 2 hours to void.
2. Place a Foley catheter now.
3. Apply warm packs to the perineum three times a day.
4. Allow the patient to rest for the next 8 hours.

Question 2

A prenatal client asks the nurse how the baby can possibly come out through her vagina, because a vagina is not nearly as big as a baby. How does the nurse best answer this client's question?

1. The vagina usually tears as it stretches during childbirth.
2. The vagina is designed to allow a baby come through.
3. The vagina changes due to pregnancy allow the vagina to stretch more.
4. The vagina dilates and effaces in labor so the baby can get out.

enass · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

1
Rationale 1: This patient is at risk for urinary retention and bladder overdistention from both the perineal edema and the effects of the epidural. Assisting the patient to the bathroom is the most likely intervention that will prevent urinary retention. If the patient is unable to void soon, a straight in-and-out catheter may be used.
Rationale 2: A Foley catheter is not indicated at this time.
Rationale 3: Cold packs will help decrease the perineal edema; warm packs would increase the edema.
Rationale 4: Waiting 8 hours to reassess the bladder is too long.

Answer to Question 2

3
Explanation: 3. The walls of the vagina are covered with ridges, or rugae, crisscrossing each other. These rugae allow the vaginal tissues to stretch enough for the fetus to pass through during childbirth.