A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation.

Exhibits

Which of the following actions should the nurse take

The correct answer is choice A. Provide the client with a cool sitz bath.

Choice A rationale:

Providing a cool sitz bath helps reduce swelling and provides pain relief for the perineum, which is crucial for a client with a fourth-degree laceration. Cool sitz baths are recommended in the initial postpartum period to soothe the area and promote healing.

After a vaginal delivery, most women experience swelling of the perineum and consequent pain. This is intensified if the woman has had an episiotomy or a laceration. Routine care of this area includes ice applied to the perineum to reduce the swelling and to help with pain relief. Conventional treatment is to use ice for the first 24 hours after delivery and then switch to warm sitz baths. However, little evidence supports this method over other methods of postpartum perineum treatment. Pain medications are helpful both systemically as nonsteroidal anti-inflammatory drugs (NSAIDs) or narcotics and as local anesthetic spray to the perineum.

Hemorrhoids are another postpartum issue likely to affect women who have vaginal deliveries. Symptomatic relief is the best treatment during this immediate postpartum period because hemorrhoids often resolve as the perineum recovers. This can be achieved by the use of corticosteroid creams, witch hazel compresses, and local anesthetics in addition to a bowel regimen that avoids constipation.

Tampon use can be resumed when the patient is comfortable inserting the tampon and can maintain it without discomfort. This often takes longer for the woman who has had an episiotomy or a laceration than for one who has not. The vagina and perineum should first be fully healed, which takes several weeks. Tampons must be changed frequently to prevent infection.

Choice B rationale:

Administering methylergonovine 0.2 mg IM is typically used to manage postpartum hemorrhage by contracting the uterus. It is not directly related to the care of a perineal laceration.

Choice C rationale:

Applying a moist, warm compress to the perineum is generally not recommended in the immediate postpartum period for a fourth-degree laceration. Warm compresses might be used later, but initially, cool treatments are preferred to reduce swelling.

Choice D rationale:

Applying povidone-iodine to the perineum after voiding is not a standard practice for managing a fourth-degree laceration. It is more important to keep the area clean and dry, and povidone-iodine can be irritating to the sensitive tissue.

Answer is: a. Urine protein of 3+

Explanation:

• Urine protein of 3+ indicates severe proteinuria, which is a sign of preeclampsia and can lead to kidney damage. The nurse should report this finding to the provider as it may require medication or delivery intervention.
• Deep tendon reflexes of 2+ are normal and do not indicate preeclampsia. The nurse should monitor the client for hyperreflexia, which is a sign of increased neuromuscular irritability and can precede seizures.
• Hemoglobin 13 g/dL is within the normal range for a pregnant client and does not indicate preeclampsia. The nurse should monitor the client for anemia, which can cause maternal and fetal complications.
• Blood glucose 110 mg/dL is slightly elevated but not diagnostic of gestational diabetes, which is a different condition from preeclampsia. The nurse should advise the client to follow a balanced diet and exercise regimen and to undergo a glucose tolerance test at 24 to 28 weeks of gestation.

.