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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When caring for a client with preeclampsia receiving magnesium sulfate, the nurse should instruct the client to report any increased muscle weakness. Magnesium sulfate is a medication commonly used to prevent and treat seizures in clients with preeclampsia. However, one of the side effects of magnesium sulfate is muscle weakness. If the client experiences an increase in muscle weakness, it could indicate magnesium toxicity, which requires immediate medical attention.
Option a) Increased respiratory rate is not typically associated with magnesium sulfate administration. However, respiratory depression is a potential side effect, so a decreased respiratory rate should be reported.
Option b) Increased fetal movement is generally considered a positive sign of fetal well-being and is not a concern that needs to be reported.
Option c) Increased urinary output is not typically a concerning finding. In fact, maintaining adequate urine output is desired in clients with preeclampsia to ensure proper kidney function. However, a sudden decrease in urinary output or signs of dehydration should be reported.
Correct Answer is B
Explanation
An ectopic pregnancy is a pregnancy that occurs outside the uterus, usually in the fallopian tube. The most common manifestation of an ectopic pregnancy is sharp pelvic pain, typically on one side. This pain is often described as severe and may be accompanied by shoulder pain or dizziness. The pain occurs because the fallopian tube is not designed to accommodate a growing embryo, leading to stretching and possible rupture of the tube.
Elevated blood pressure is not typically associated with an ectopic pregnancy. Blood pressure changes may occur in other conditions, such as preeclampsia, but it is not a characteristic manifestation of an ectopic pregnancy.
Bright red vaginal discharge is not a typical manifestation of an ectopic pregnancy. Vaginal bleeding may occur, but it is usually darker and more like a menstrual flow. Bright red vaginal discharge may indicate other conditions, such as a threatened miscarriage or a vaginal infection.
A scaphoid abdomen (a concave or sunken appearance of the abdomen) is not a specific manifestation of an ectopic pregnancy. It may be seen in conditions like malnutrition or dehydration, but it is not directly related to an ectopic pregnancy.
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