A nurse is planning care for a client who is 12 hr postpartum and has a third-degree perineal laceration. Which of the following interventions should the nurse include in the plan?

A. I will receive a series of three immunizations, and each one will be a month apart: This statement is not accurate for rubella immunization. The MMR vaccine is usually administered as a single injection.

B. I should avoid becoming pregnant for at least 1 month following the immunization

Rubella immunization is typically administered as the measles, mumps, and rubella (MMR) vaccine. The statement indicating understanding reflects awareness of the importance of avoiding pregnancy for a certain period after receiving the rubella immunization due to potential risks to the developing fetus.

C. I should avoid breastfeeding for 2 weeks following the immunization: Breastfeeding is not a contraindication after receiving the rubella immunization. In fact, breastfeeding is generally not affected, and mothers can continue to breastfeed.

D. I will report joint pain that develops after the immunization to my provider immediately: Joint pain is a potential side effect of the rubella vaccine. Reporting joint pain to the provider is essential for monitoring and addressing any adverse reactions.

A. Administer oxygen via face mask at 10 L/min: While oxygen administration may be necessary for a client experiencing excessive bleeding, the first action should be to assess the extent of blood loss. Administering oxygen is not the priority at this point.

B. Prepare the client to receive plasma expander: Plasma expanders, such as intravenous fluids, may be part of the treatment for postpartum hemorrhage, but the immediate priority is to assess the client's blood loss and determine the need for blood products. Fluid replacement alone may not address the underlying issue.

C. Collect hemoglobin and hematocrit levels: This is the correct first action. Hemoglobin and hematocrit levels provide crucial information about the extent of blood loss and the need for further interventions, such as blood transfusions. This information helps guide the overall management of the client.

D. Insert an indwelling urinary catheter: While assessing urinary output is important, it is not the first priority when a client is saturating perineal pads every 10 to 15 minutes. The immediate concern is to assess and manage the excessive bleeding, and obtaining hemoglobin and hematocrit levels is a crucial step in this process.