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 A
Explanation
A.It is normal for a yellow exudate to form at the surgical site within 24 hours after a Plastibell circumcision.This is part of the healing process and should not be mistaken for an infection.
B.The Plastibell device is not removed manually.It typically falls off on its own within 7 to 10 days.
C.The diaper should be loose to avoid pressure on the circumcised area, which can cause discomfort and delay healing.
D.It is normal for the area around the Plastibell to darken as the tissue dies and the ring prepares to fall off.However, parents should notify the provider if there are signs of infection, excessive bleeding, or if the Plastibell does not fall off within the expected time frame.
Correct Answer is C
Explanation
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today