A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take?

The correct answer is A. Initiate continuous monitoring of the FHR. For a client with placenta previa, continuous fetal heart rate (FHR) monitoring is essential to assess the baby's well-being due to the risk of fetal distress from reduced oxygen supply

Choice A reason:

Continuous FHR monitoring is a standard care practice for clients with placenta previa to promptly detect any signs of fetal distress and intervene as necessary.

Choice B reason:

Betamethasone is typically administered to enhance fetal lung maturity before 34 weeks of gestation, not for placenta previa. Its use at 35 weeks is less common unless there's a risk of preterm birth within 7 days and the patient hasn't received a previous course.

Choice C reason:

Checking the cervix can induce bleeding and is contraindicated in placenta previa because it may disturb the placental site and exacerbate bleeding.

Choice D reason:

Misoprostol is used for labor induction or to treat postpartum hemorrhage. It is not indicated for placenta previa management and can cause uterine contractions leading to increased bleeding.

Choice A rationale:

Assessing for bladder distention is important for postpartum clients, especially those who have undergone perineal trauma during childbirth. However, it is not the priority assessment during a sitz bath. The sitz bath is usually done to promote healing and comfort, and monitoring pulse rate takes precedence to identify any adverse reactions.

Choice B rationale:

Pulse rate should be the priority assessment during a sitz bath for a postpartum client. Sitz baths can cause vasodilation, leading to a potential drop in blood pressure, increased heart rate, or dizziness. Monitoring the pulse rate helps identify any cardiovascular changes or adverse reactions.

Choice C rationale:

Respiratory rate is not the priority assessment during a sitz bath. It is essential to monitor, but it is less likely to be affected directly by the sitz bath compared to the pulse rate and cardiovascular changes.

Choice D rationale:

Monitoring the color of lochia is essential for assessing postpartum bleeding and uterine healing. However, during a sitz bath, the priority assessment should be focused on cardiovascular changes and any adverse reactions the client might experience.