1. A nurse is caring for a newborn immediately following birth.

Exhibit 1

Medical History

Vacuum-assisted vaginal birth

Maternal history of positive group B streptococcus 8-hemolytic Mother received two doses of ampicillin IV bolus during labor

Exhibit 2

Vital Signs

Apgar:

Heart rate 96/min

Weak cry

Muscle tone: some flexion

Reflex: grimace

Color: acrocyanosis

Axillary temperature 36.9° C (98.5° F)

Exhibit 3

Medications

Erythromycin ophthalmic ointment once 1 to 2 hr after birth Hepatitis B vaccine 10 mcg/0.5 mL IM once within 24 hr after birth

Phytonadione 1 mg IM once 1 to 2 hr after birth

Exhibit 4

Laboratory Findings

WBC count 15,000mm (9,000 to 30,000/mm)

Hgb 19 g/dl (15 to 24 g/dL)

HCt 57% (44% to 70%)

Blood glucose 44 mg/dl (40 to 60 mg/dL)

The nurse is assessing the newborn 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or indication that the client's condition is worsening

a.This may help with incision pain or swelling but does not address the ongoing vaginal bleeding.

b.Administering a bolus of lactated Ringer's solution helps to restore fluid volume and maintain blood pressure, which is crucial in managing persistent vaginal bleeding. This action addresses the immediate concern of fluid loss and helps stabilize the patient while further assessments and interventions can be made.

c.While important for monitoring the incision, it does not address the immediate issue of ongoing vaginal bleeding.

d.Important to monitor, but not the first priority in the context of ongoing bleeding. This can be assessed after addressing the bleeding issue.

A. Encourage the client to apply a warm pack to the perineum for discomfort.

While warm packs can provide comfort and promote relaxation for some types of perineal discomfort, they may not be suitable for a third-degree perineal laceration. In fact, applying heat directly to the perineum may exacerbate swelling and increase discomfort in this particular case. Therefore, it is not the most appropriate intervention for this client.

B. Prepare the client for a pudendal nerve block.

A pudendal nerve block is typically used during labor or for specific procedures (such as episiotomy repair) to provide pain relief. It is not a routine intervention for postpartum perineal lacerations.

C. Apply hydrogel pads to the perineum every 4 hr.

While hydrogel pads can provide some relief for perineal discomfort, they are not typically used specifically for third-degree perineal lacerations. These types of lacerations require medical intervention and repair rather than solely relying on over-the-counter remedies like hydrogel pads. Therefore, this intervention may not address the underlying issue effectively.

D. Place a witch hazel pad on the client's perineal pad after each voiding.

Witch hazel pads can provide soothing relief to the perineum and help reduce swelling and discomfort after childbirth. They have a cooling effect and can also have mild astringent properties, which may aid in promoting healing.Placing a witch hazel pad on the perineal pad after each voiding helps ensure that the perineum remains clean and that the client experiences continuous relief from discomfort