Maternity Nursing: Postpartum Q 3
A nurse is developing a plan of care for a PP woman with a small vulvar hematoma. The nurse includes which specific intervention in the plan during the first 12 hours following the delivery of this client?
A. Assess vital signs every 4 hours.
B. Inform health care providers of assessment findings.
C. Measure fundal height every 4 hours.
D. Prepare an ice pack for application to the area.
Correct Answer: D. Prepare an ice pack for application to the area.
Option D: Application of ice will reduce swelling caused by hematoma formation in the vulvar area. During labor, a vulvar hematoma can result from either direct or indirect injury to the soft tissue. Examples of causes of direct injuries include episiotomy, vaginal laceration repairs, or instrumental deliveries, while indirect injury can result from extensive stretching of the birth canal during vaginal delivery.