A nurse is teaching the parents of a newborn how to care for their child's uncircumcised penis. Which of the following instructions should the nurse include?

Choice A rationale:

Assessing for bladder distention is important for postpartum clients, especially those who have undergone perineal trauma during childbirth. However, it is not the priority assessment during a sitz bath. The sitz bath is usually done to promote healing and comfort, and monitoring pulse rate takes precedence to identify any adverse reactions.

Choice B rationale:

Pulse rate should be the priority assessment during a sitz bath for a postpartum client. Sitz baths can cause vasodilation, leading to a potential drop in blood pressure, increased heart rate, or dizziness. Monitoring the pulse rate helps identify any cardiovascular changes or adverse reactions.

Choice C rationale:

Respiratory rate is not the priority assessment during a sitz bath. It is essential to monitor, but it is less likely to be affected directly by the sitz bath compared to the pulse rate and cardiovascular changes.

Choice D rationale:

Monitoring the color of lochia is essential for assessing postpartum bleeding and uterine healing. However, during a sitz bath, the priority assessment should be focused on cardiovascular changes and any adverse reactions the client might experience.

Choice A rationale:

Terbutaline is a medication commonly used to stop preterm labor by relaxing the uterine muscles. However, it is contraindicated in clients with heart disease or certain cardiac conditions, as it can cause cardiovascular side effects such as increased heart rate, palpitations, and potential arrhythmias.

Choice B rationale:

Cervical dilation of 2 cm is a typical sign of preterm labor, and the prescription for terbutaline is appropriate to prevent further cervical dilation and delay delivery.

Choice C rationale:

A gestational age of 34 weeks indicates preterm labor, which is precisely the scenario where terbutaline would be administered to halt labor progression and extend the pregnancy.

Choice D rationale:

Allergy to penicillin is unrelated to the administration of terbutaline, as they are different medications with distinct mechanisms of action and side effects.