A nurse is planning care for a patient who is 12 hours postpartum and has a third-degree perineal laceration. Which of the following interventions should the nurse include in the plan?

Prepare the patient for a pudendal nerve block

Apply hydrogel pads to the perineum every 4 hours

Encourage the patient to apply a warm pack to the perineum for discomfort

Place a witch hazel pad on the patient’s perineal pad after each voiding

Answer and Explanation

The Correct Answer is D

Choice A rationale
A pudendal nerve block is not typically used for postpartum perineal pain management. It is more commonly used during labor to relieve pain in the perineum and vagina.
Choice B rationale
While hydrogel pads can provide cooling relief, they are not typically used for third-degree perineal lacerations. These types of lacerations often require more intensive interventions.
Choice C rationale

Applying a warm pack to the perineum can help with discomfort, but it is not the primary intervention for a third-degree perineal laceration.
Choice D rationale
Witch hazel pads are often recommended for postpartum perineal care. They can provide relief from soreness, reduce inflammation, and promote healing.

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Correct Answer is []

Explanation

Condition: The client is most likely expeíiencing Placenta píevia. This condition is chaíacteíized by painless, bíight íed vaginal bleeding duíing the thiíd tíimesteí, which matches the client’s symptoms.
Actions:

1. Instíuct the client to maintain bed íest: This can help to píevent fuítheí bleeding.
2. Píepaíe the client foí a possible ultíasound: An ultíasound can help to confiím the diagnosis and assess the placental location and fetal well-being.

Paíameteís to Monitoí:

1. Ïetal heaít íate: Monitoíing the fetal heaít íate can help to assess the baby’s well-being.
2. Hemoglobin and hematocíit levels: These should be monitoíed to assess the client’s blood loss and íisk of anemia.

A. Prepare the client to receive a plasma expander. B. Administer oxygen via face mask at 10 L/min. C. Insert an indwelling urinary catheter. D. Collect hemoglobin and hematocrit levels.

Correct Answer is B

Explanation

Choice A rationale
Preparing the client to receive a plasma expander is not the first action the nurse should take. While it may be necessary in severe cases of hemorrhage, the first action should be to ensure the client’s oxygenation.
Choice B rationale
Administering oxygen via face mask at 10 L/min is the first action the nurse should take. This is because a client who is saturating perineal pads every 10 to 15 minutes is likely experiencing a significant blood loss, which can lead to hypoxia.
Choice C rationale
Inserting an indwelling urinary catheter may be necessary in some cases, but it is not the first action the nurse should take.
Choice D rationale
Collecting hemoglobin and hematocrit levels is important to assess the extent of blood loss, but it is not the first action the nurse should take.

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A nurse is planning care for a patient who is 12 hours 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

Correct Answer is []

Explanation

A nurse is assessing a client who is 6 hr postpartum and is saturating perineal pads every 10 to 15 min. What actions should the nurse take first?

Correct Answer is B

Explanation

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