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 B

Explanation

. Protective environment: Protective environment precautions are used for clients with compromised immune systems, such as those undergoing stem cell transplantation. This precaution aims to protect the client from exposure to environmental pathogens.

B. Contact: This is the correct answer. Contact Precautions are appropriate for clients with C. difficile infection. The precautions include using gloves and gowns when entering the room and ensuring proper hand hygiene to prevent the transmission of the bacteria.

C. Droplet: Droplet precautions are used for diseases that are transmitted through respiratory droplets, such as influenza or pertussis. C. difficile is not primarily transmitted through respiratory droplets.

D. Airborne: Airborne precautions are used for diseases that can be transmitted by tiny particles suspended in the air, such as tuberculosis or chickenpox. C. difficile is not transmitted through the airborne route.

A. Subcutaneous in the left vastus lateralis B. IM in right deltoid C. IM in left vastus lateralis D. Subcutaneous in the right deltoid

Correct Answer is C

Explanation

A. Subcutaneous in the left vastus lateralis: Phytonadione is usually administered IM, not subcutaneously. The vastus lateralis muscle in the thigh is a common site for IM injections in newborns.

B. IM in the right deltoid: The deltoid muscle in the upper arm is not typically the recommended site for administering medications to newborns. The vastus lateralis muscle in the thigh is preferred for newborn IM injections due to better muscle development and blood flow.

C. IM in the left vastus lateralis: This is the correct option. Phytonadione, or Vitamin K, is routinely given to newborns to prevent vitamin K deficiency bleeding (VKDB). It's administered as an IM injection into the vastus lateralis muscle in the thigh, which is a standard practice for newborn vitamin K administration.

D. Subcutaneous in the right deltoid: Subcutaneous administration in the deltoid is not typically used for newborns, especially for medications like phytonadione that are commonly administered IM.

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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?

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