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

A. Hot flashes: Hot flashes are not a typical adverse effect of terbutaline. Hot flashes are more commonly associated with hormonal changes, such as those that occur during menopause.

B. Heart palpitations: This is the correct answer. Terbutaline can stimulate beta-2 receptors in the heart, leading to increased heart rate and palpitations. Clients receiving terbutaline should be monitored for cardiac side effects.

C. Shortness of breath: While terbutaline is used to relax smooth muscles, it can also affect beta-2 receptors in the respiratory system. However, shortness of breath is not a common adverse effect and may indicate other respiratory issues.

D. Bradycardia: Bradycardia, or a slow heart rate, is not a typical adverse effect of terbutaline. The medication is more likely to increase heart rate due to its beta-2 adrenergic agonist properties.

A. Give oxytocin 20 units IV bolus B. Obtain serial hemoglobin and hematocrit C. Perform a fundal massage D. Assess for abdominal tenderness

Correct Answer is B

Explanation

A. Give oxytocin 20 units IV bolus: Oxytocin is a medication used to induce or augment labor, and it is not the appropriate intervention for a client with placenta previa and significant vaginal bleeding. The priority in this situation is to assess and manage the bleeding.

B. Obtain serial hemoglobin and hematocrit: This is the correct action. Placenta previa can lead to significant bleeding, and obtaining serial hemoglobin and hematocrit levels will help monitor the extent of blood loss and guide decisions regarding transfusions or other interventions.

C. Perform a fundal massage: Fundal massage is not the appropriate intervention for placenta previa. In cases of placenta previa, the placenta is covering or near the cervical os, and vigorous fundal massage can worsen bleeding.

D. Assess for abdominal tenderness: While assessing for abdominal tenderness is important in the overall assessment of a pregnant client, in the context of active bleeding with placenta previa, the immediate focus should be on assessing the extent of bleeding and the client's hemodynamic status.

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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

A nurse is caring for a client who is receiving terbutaline to treat preterm labor. Which of the following findings should the nurse identify as a potential adverse effect of this medication?

Correct Answer is B

Explanation

A nurse is caring for a client who is at 32 weeks of gestation and has placenta previa. The client is exhibiting a large amount of vaginal bleeding. Which of the fallowing actions should the nurse take?

Correct Answer is B

Explanation

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