A nurse is obtaining a 2-hr postprandial blood glucose from a client. Which of the following actions should the nurse take?

Explanation

Choice A Reason:

Vigorously massaging the injection site is not recommended as it may increase discomfort or bruising at the injection site. Gentle pressure may be applied if necessary, but vigorous massage is not necessary.

Choice B Reason:

Inserting the needle at a 45° angle for injection is incorrect. When administering intramuscular injections to newborns, the needle is typically inserted at a 90° angle (perpendicular to the skin) to ensure proper delivery of the vaccine into the muscle. A 45° angle is more commonly used for subcutaneous injections.

Choice C Reason;

Using a 21-gauge needle for the injection is incorrect. The gauge of the needle refers to its thickness. While the gauge of the needle used for intramuscular injections can vary depending on the specific vaccine and patient factors, a 21-gauge needle may be too large for a newborn. Smaller gauge needles, such as 23-25 gauge, are typically used for newborns to minimize discomfort.

Choice D Reason:

Administering the injection into the vastus lateralis muscle is correct. When administering a hepatitis B vaccine to a newborn, it is typically given intramuscularly. The vastus lateralis muscle, located in the thigh, is one of the recommended sites for intramuscular injections in infants. It is important to choose an appropriate muscle for injection to ensure proper absorption of the vaccine.

Explanation

Choice A Reason:

Applying povidone-iodine to the client's perineum after she voids is inappropriate. Povidone-iodine is an antiseptic solution commonly used for wound cleansing, but it is not typically indicated for application to perineal lacerations. Applying povidone-iodine to the perineum may cause irritation and delay wound healing. Instead, perineal care for a fourth-degree laceration usually involves gentle cleansing with warm water and patting dry.

Choice C Reason:

For a client who is 12 hours postpartum with a fourth-degree laceration, providing a cool sitz bath is an appropriate action. This can help reduce swelling, provide comfort, and promote healing in the perineal area. Cool sitz baths can be particularly soothing and beneficial in managing discomfort associated with perineal lacerations.

Choice C Reason:

Administering methylergonovine 0.2 mg IM is inappropriate .Methylergonovine is a medication used to prevent or treat postpartum hemorrhage by causing uterine contractions. However, it is not indicated for pain relief or wound management in clients with perineal lacerations. Administering methylergonovine to a client with a fourth-degree laceration without appropriate indication could lead to adverse effects such as increased uterine tone or hypertonic contractions.

Choice D Reason:

While warm compresses can promote comfort and healing, applying a warm compress immediately after childbirth and with a fourth-degree laceration may not be appropriate as it can increase swelling. Generally, cool therapies are recommended initially for acute swelling and pain relief.