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?
Place a witch hazel pad on the client's perineal pad after each voiding
Apply hydrogel pads to the perineum every 4 hr
Prepare the client for a pudenal nerve block
Encourage the client to apply a warm pack to the perineum for discomfort
The Correct Answer is B
A. Place a witch hazel pad on the client's perineal pad after each voiding: Witch hazel pads can provide relief from perineal discomfort, but they are typically used in the immediate postpartum period for general comfort rather than specifically for third-degree perineal lacerations.
B. Apply hydrogel pads to the perineum every 4 hr: Hydrogel pads can help soothe and cool the perineal area, providing relief from pain and discomfort. This intervention is appropriate for third-degree perineal lacerations.
C. Prepare the client for a pudendal nerve block: Pudendal nerve blocks are typically used for pain relief during the second stage of labor and delivery. They are not a standard intervention for managing third-degree perineal lacerations postpartum.
D. Encourage the client to apply a warm pack to the perineum for discomfort: While warm packs can provide comfort, they are generally not recommended for third-degree perineal lacerations. Cold packs or hydrogel pads are often more appropriate for reducing swelling and providing relief in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. This infection requires that airborne precautions be initiated for the newborn: Cytomegalovirus (CMV) is not typically transmitted through the airborne route. It is primarily spread through direct contact with infected bodily fluids, such as saliva, urine, blood, and genital secretions.
B. Transmission can occur via the saliva and urine of the newborn: CMV can be transmitted through close contact with infected bodily fluids, including saliva and urine. Newborns can contract CMV during delivery or through contact with their mother's infected bodily fluids.
C. Lesions are visible on the mother’s genitalia: Unlike some other viral infections, CMV does not typically present with visible lesions on the genitalia. CMV infection may be asymptomatic or cause mild symptoms in healthy individuals.
D. Mothers will receive prophylactic treatment with acyclovir prior to delivery: Acyclovir is an antiviral medication used to treat herpes simplex virus (HSV) infections, not CMV. There is no standard antiviral prophylactic treatment for CMV in pregnancy.
Correct Answer is A
Explanation
A. The client’s fundus is firm and midline: Oxytocin is commonly administered in the third stage of labor to promote uterine contraction and prevent postpartum hemorrhage. A therapeutic effect of oxytocin is the firm and midline positioning of the uterus, indicating effective contraction and the prevention of excessive bleeding.
B. The client’s umbilical cord lengthens: The lengthening of the umbilical cord is not an expected therapeutic effect of oxytocin administration. Oxytocin primarily affects uterine contractions.
C. The client reports a feeling of vaginal fullness: A feeling of vaginal fullness is not a typical therapeutic effect of oxytocin administration. It may be associated with other factors, such as the presence of blood clots or retained placental fragments, and should be further assessed.
D. The client saturates a perineal pad in 1 hour: Saturating a perineal pad in 1 hour is not an expected therapeutic effect of oxytocin. Excessive bleeding or saturation of perineal pads may be a sign of postpartum hemorrhage and requires immediate attention.
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