A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

Choice A reason:

Assisting the client on a bedpan to urinate can help if the bladder is full, as a full bladder can impede uterine contraction and contribute to bleeding. However, this is not the immediate priority. The primary concern is to control the bleeding, which requires more direct intervention.

Choice B reason:

Increasing the client’s fluid intake is important for maintaining hydration, especially if there is significant blood loss. However, this action does not directly address the cause of the bleeding. Immediate measures to control the hemorrhage are more critical.

Choice C reason:

Palpating the client’s uterine fundus is an essential step in assessing the cause of the bleeding. If the uterus is not contracting properly (uterine atony), it can lead to excessive bleeding. However, while this assessment is crucial, it is not the definitive intervention to stop the bleeding.

Choice D reason:

Preparing to administer oxytocic medication is the priority intervention. Oxytocic drugs, such as oxytocin (Pitocin), stimulate uterine contractions, which help to control and reduce postpartum hemorrhage. Administering this medication promptly can effectively manage the bleeding and prevent further complications.

Choice A reason:

The statement “Provide bedtime rituals” is correct. Establishing a consistent bedtime routine can help toddlers feel more secure and relaxed, which can promote better sleep. Bedtime rituals might include reading a story, singing a lullaby, or having a warm bath before bed. These activities signal to the child that it is time to wind down and prepare for sleep.

Choice B reason:

The statement “Encourage play exercises in the evening” is incorrect. While physical activity is important for overall health, engaging in stimulating play exercises right before bedtime can make it harder for toddlers to settle down and fall asleep. It is better to encourage quiet, calming activities in the evening.

Choice C reason:

The statement “Explain the source of the toddler’s fears” is not the most effective approach for promoting sleep. While addressing fears is important, the explanation alone may not be sufficient to help the toddler feel secure enough to sleep. Providing comfort and reassurance through bedtime rituals is more effective in creating a sense of safety.

Choice D reason:

The statement “Turn off the room light” is partially correct but not the best standalone solution. While a dark environment can promote sleep, some toddlers may feel more secure with a nightlight. The focus should be on creating a calming and comfortable sleep environment, which includes but is not limited to adjusting the lighting.