A nurse is caring for a client who is 12 hours postpartum and has a fourth-degree laceration of the perineum. The nurse should take which of the following actions?

Provide the client with a cool sitz bath.

Administer methylergonovine 0.2 mg IM.

Apply povidone-iodine to the client's perineum after she voids.

Apply a moist, warm compress to the perineum.

Answer and Explanation

The Correct Answer is D

A fourth-degree laceration involves a tear that extends through the perineal muscles and extends to the anal sphincter. This type of laceration requires careful management to promote healing and prevent infection. Applying a moist, warm compress to the perineum helps to promote blood ﬂow, reduce swelling, and provide comfort to the client.

Option a) Providing the client with a cool sitz bath is not appropriate for a fourth-degree laceration. Cool sitz baths are typically used for relieving discomfort and reducing swelling in cases of perineal trauma, but in the case of a fourth-degree laceration, warm compresses are preferred.
Option b) Administering methylergonovine 0.2 mg IM is not necessary for a fourth-degree laceration. Methylergonovine is a medication used to promote uterine contractions and prevent postpartum hemorrhage. However, it is not specifically indicated for the management of perineal lacerations.
Option c) Applying povidone-iodine to the client's perineum after she voids is not recommended for a fourth-degree laceration. Povidone-iodine is an antiseptic solution used to disinfect the skin. However, it is not typically used on open wounds, such as perineal lacerations, as it may delay wound healing.

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Correct Answer is ["A","D","E"]

Explanation

These are the findings that place the client at risk for postpartum hemorrhage. Postpartum hemorrhage (PPH) is severe vaginal bleeding after childbirth. It can be a life-threatening condition that requires prompt treatment. The most common cause of PPH is uterine atony, which is when the uterus does not contract enough to stop the bleeding from the placental site¹. Factors that can increase the risk of uterine atony include:
- History of uterine atony: Having a previous episode of PPH due to uterine atony makes it more likely to
happen again in subsequent deliveries.
- Labor induction with oxytocin: Oxytocin is a hormone that stimulates uterine contractions. However, prolonged or excessive use of oxytocin during labor can cause uterine fatigue and reduce its ability to contract after delivery.
- Vacuum-assisted delivery: A vacuum extractor is a device that helps deliver the baby by applying suction to the baby's head. This can cause trauma to the uterus and increase the risk of bleeding.

The other options are not correct because they are not risk factors for postpartum hemorrhage. Let me
explain why:
b) History of human papillomavirus
Human papillomavirus (HPV) is a common sexually transmited infection that can cause genital warts and cervical cancer. However, it does not increase the risk of postpartum hemorrhage. HPV may aﬀect the cervix, but not the uterus or the placenta, which are the main sources of bleeding after delivery³.
c) Newborn weight 2.948 kg (6 Ib 8 oz)

This is a normal newborn weight and does not increase the risk of postpartum hemorrhage. A large baby (more than 4 kg or 8.8 Ib) may increase the risk of uterine atony by overdistending the uterus, but this is not the case for this newborn².

A. "The nurse should determine the Apgar score at 2 and 7 minutes after birth." B. "The nurse should identify that the newborn is in severe distress with an Apgar score of 8." C. "The nurse should wait for the first Apgar score before initiating resuscitation eﬀorts." D. "The nurse should measure the newborn's muscle tone when assigning an Apgar score."

Correct Answer is D

Explanation

The Apgar score is a method for assessing the health and well-being of a newborn baby immediately after birth. It is based on five criteria: appearance (skin color), pulse (heart rate), grimace (reﬂex irritability), activity (muscle tone), and respiration (breathing eﬀort). Each criterion is given a score of 0, 1, or 2, depending on the baby's condition. The total score ranges from 0 to 10, with higher scores indicating better health. The Apgar score is determined at one and five minutes after birth, and sometimes at 10 minutes if the score is low or the baby needs resuscitation. The purpose of the Apgar score is to identify babies who need immediate medical attention and to monitor their response to treatment. The Apgar score is not a predictor of long-term outcomes or developmental problems .
One of the criteria that the nurse should measure when assigning an Apgar score is muscle tone. Muscle tone refers to the degree of tension or stiﬀness in the baby's muscles. It reﬂects the baby's neuromuscular function and oxygenation. Muscle tone can be assessed by observing the baby's posture, movement, and resistance to passive ﬂexion or extension of the limbs .
The scoring system for muscle tone is as follows:
- Score 0: No movement; limp and ﬂoppy
- Score 1: Some ﬂexion of arms and legs; weak or sluggish movement
- Score 2: Active movement; arms and legs ﬂexed and resist extension
Therefore, the newly hired nurse who says that the nurse should measure the newborn's muscle tone
when assigning an Apgar score indicates an understanding of the teaching.

The other statements show a lack of knowledge or misunderstanding of the Apgar scoring:
- a) "The nurse should determine the Apgar score at 2 and 7 minutes after birth." This is not correct because the standard times for determining the Apgar score are one and five minutes after birth, not two and seven minutes. The one-minute score reﬂects how well the baby tolerated the delivery process, while the five-minute score reﬂects how well the baby adapted to the extrauterine environment .
- b) "The nurse should identify that the newborn is in severe distress with an Apgar score of 8." This is not correct because an Apgar score of 8 indicates that the newborn is in good condition and does not need any intervention. An Apgar score of 7 to 10 means that the newborn has normal vital signs and reﬂexes and only needs routine care. An Apgar score of 4 to 6 means that the newborn has moderate distress and may need some assistance with breathing or stimulation. An Apgar score of 0 to 3 means that the newborn has severe distress and needs immediate resuscitation .
- c) "The nurse should wait for the first Apgar score before initiating resuscitation eﬀorts." This is not correct because waiting for the first Apgar score can delay life-saving interventions for a newborn who needs resuscitation. The nurse should initiate resuscitation eﬀorts as soon as possible if the newborn shows any signs of distress, such as apnea, gasping, cyanosis, bradycardia, or poor muscle tone. The nurse should not rely on the Apgar score alone to decide whether to resuscitate or not, but use it as a tool to monitor the baby's response to treatment .

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A nurse is caring for a client who is 12 hours postpartum and has a fourth-degree laceration of the perineum. The nurse should take which of the following actions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

A nurse is teaching a newly hired nurse about Apgar scoring. Which of the following statements by the newly hired nurse indicates an understanding of the teaching?

Correct Answer is D

Explanation

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