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
This is the food that the nurse should recommend to the client who practices a vegan diet and is trying to increase intake of vitamin B2. Vitamin B2, also known as riboflavin, is an essential nutrient that is involved in energy metabolism, growth, and cell function¹. It is found in small amounts in a variety of plant foods, such as avocados, mushrooms, almonds, leafy green vegetables, and soybeans³. However, some of the best sources of riboflavin are animal products, such as dairy products and eggs¹. Therefore, vegans may need to consume fortified foods or supplements to meet their daily requirements of riboflavin.
Fortified soy milk is a good option for vegans because it contains added riboflavin, as well as other nutrients such as calcium, vitamin B12, and vitamin D. One cup of fortified soy milk can provide about 0.5 milligrams of riboflavin, which is about 45% of the recommended daily amount for women and 38% for men⁴. Other fortified vegan foods that may contain riboflavin include breakfast cereals, nutritional yeast, and plant- based meat alternatives²⁵.
The other options are not correct because they are not good sources of riboflavin.
a) Raw carrots
Raw carrots are a healthy vegetable that provide vitamin A, fiber, and antioxidants. However, they are not a good source of riboflavin. One medium carrot contains only 0.02 milligrams of riboflavin, which is less than 2% of the recommended daily amount⁴.
b) Fresh citrus fruits
Fresh citrus fruits are a great source of vitamin C, folate, and potassium. However, they are not a good source of riboflavin. One medium orange contains only 0.04 milligrams of riboflavin, which is about 4% of the recommended daily amount⁴.
c) Brown rice
Brown rice is a whole grain that provides complex carbohydrates, fiber, and minerals. However, it is not a good source of riboflavin. One cup of cooked brown rice contains only 0.05 milligrams of riboflavin, which is about 5% of the recommended daily amount⁴.

Correct Answer is D
Explanation
In a newborn, bluish discoloration of the hands and feet may indicate a condition called peripheral cyanosis, which suggests poor oxygenation. It is important to report this finding to the healthcare provider promptly, as it may indicate a respiratory or circulatory problem that requires immediate attention.
Option a) Overlapping of the cranial bones is a common finding in newborns due to the molding of the head during delivery. This is not a priority finding to report unless there are other signs of concern, such as abnormal head shape or signs of trauma.
Option b) Small, distended white sebaceous glands on the face are called milia and are a normal finding in newborns. They are not a priority finding to report and typically resolve on their own within a few weeks.
Option c) Forward and lateral positioning of the ears is a normal finding in a newborn and is not a priority to report. The ears may appear folded or positioned differently due to the pressure and positioning in the womb.
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