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 C
Explanation
A. Intense contractions lasting 45 to 60 seconds: Intense contractions within a normal duration are typical during the active phase of labor. This finding does not necessarily warrant immediate reassessment but rather ongoing monitoring.
B. A sense of excitement and warm, flushed skin: A sense of excitement and warm, flushed skin may be associated with the transition phase of labor and is not necessarily a cause for immediate concern.
C. An urge to have a bowel movement during contractions: This is the correct answer. The urge to have a bowel movement may indicate fetal descent and the need to assess for full cervical dilation. It could signal the need for imminent delivery, and the nurse should promptly assess the client's cervix and notify the healthcare provider.
D. Progressive sacral discomfort during contractions: Discomfort, including sacral discomfort, is common during labor. Progressive sacral discomfort may be associated with the normal progression of labor and is not a reason for immediate reassessment.
Correct Answer is D
Explanation
A. Applying hydrating lotion to the newborn's skin prior to treatment is not recommended as lotions or creams can interfere with the effectiveness of phototherapy and may increase the risk of skin irritation or burns.
B. Turning the newborn every 4 hours is insufficient; the newborn should be turned more frequently, typically every 2 hours, to ensure even exposure to the phototherapy light and to prevent pressure sores.
C. Provide the newborn with 15 ml glucose water after each feeding: This is not a standard practice related to phototherapy. Feeding frequency and amounts are determined by the infant's age, weight, and feeding readiness, but providing glucose water after each feeding is not a routine recommendation.
D. Close the newborn's eyes before applying eyepatches: This is the correct answer. Eyepatches are used during phototherapy to protect the newborn's eyes from exposure to the bright lights. Closing the newborn's eyes before applying eyepatches helps shield the eyes from the light source and prevents potential damage to the eyes.
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