After a forceps-assisted birth, the client is observed to have ...

[scienceeasy]

After a forceps-assisted birth, the client is observed to have continuous bright red lochia but a firm fundus. Which other data would indicate the presence of a potential vaginal wall hematoma?
 
  a. Lack of an episiotomy
  b. Mild, intermittent perineal pain
  c. Lack of pain in the perineal area
  d. Edema and discoloration of the labia and perineum

Question 2

The nurse knows that a urinary catheter is added to the instrument table if a forceps-assisted birth is anticipated. The correct rationale for this intervention is that:
 
  a. a sterile urine specimen is needed preoperatively.
  b. an empty bladder provides more room in the pelvis.
  c. spontaneous release of urine might contaminate the sterile field.
  d. a Foley catheter prevents the membranes from spontaneously rupturing.

[jackie]

Answer to Question 1

ANS: D
The nurse should monitor for edema and discoloration. Using a cold application to the labia and perineum reduces pain by numbing the area and limiting bruising and edema for the first 12 hours. An episiotomy is performed as the fetal head distends the perineum. The pain with vaginal hematoma is severe and constant. The pain associated with vaginal hematoma is severe.

Answer to Question 2

ANS: B
Catheterization provides room for the application of the forceps blades and limits bladder trauma. A clean-catch urinalysis is usually sufficient for preoperative treatment. Urine is sterile. The membranes must be ruptured and the cervix completely dilated for a forceps-assisted birth.

[scienceeasy]

Excellent

[Zebsrer]

TYSM