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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Report of perineal pain as 0 on a scale of 0 to 10: Perineal pain is more directly related to the effects of spinal anesthesia rather than fluid status. A decrease in perineal pain would be expected after the administration of spinal anesthesia, but it may not specifically indicate the effectiveness of the IV bolus.

B. Report of relief of pruritus: Pruritus (itching) is a common side effect of spinal anesthesia. Relief of pruritus can be expected after the administration of spinal anesthesia, but it is not a direct indicator of the effectiveness of the IV bolus.

C. Increased urinary output: Increased urinary output may indicate improved renal perfusion or fluid balance but is not a specific indicator of the effectiveness of the IV bolus in the context of spinal anesthesia for labor.

D. Blood pressure 110/70 mm Hg: This is the correct answer. Blood pressure is an important parameter to monitor, especially after administering an IV bolus of fluids. A blood pressure within the normal range (110/70 mm Hg) suggests that the bolus has been effective in addressing any hypovolemia or dehydration.

A. Ensure the call button is within the client's reach B. Place the suction equipment at the client’s bedside C. Pad the side rails of the client's bed D. Dim the lights in the client’s room

Correct Answer is C

Explanation

A. Ensure the call button is within the client's reach: While having the call button within reach is important for the client to summon assistance quickly, the immediate priority is to prevent injury during a seizure. Padding the side rails takes precedence.

B. Place the suction equipment at the client’s bedside: While suction equipment may be necessary in certain situations, it is not the priority when implementing seizure precautions for a client with preeclampsia. The primary focus is on preventing injury during a seizure.

C. Pad the side rails of the client's bed : Seizure precautions aim to create a safe environment for a patient at risk of seizures. In the context of preeclampsia, the potential complication is eclampsia, which involves the occurrence of seizures. Padding the side rails of the bed is a priority because it helps prevent injury to the client during a seizure. In the event of a seizure, the client may move uncontrollably, and padding the side rails reduces the risk of injury if the client strikes the rails.

D. Dim the lights in the client’s room: Dimming the lights is not the priority when implementing seizure precautions. The focus should be on creating a safe environment to prevent injury during a seizure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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