The nurse is planning care for a client who has a fourth degree midline laceration that occurred during vaginal delivery of an 8-pound 10-ounce (3674 grams) infant. Which intervention has the highest priority for this client?

Administer prescribed PRN sleep medications.

Encourage use of prescribed analgesic perineal sprays.

Encourage breastfeeding to promote uterine involution.

Administer prescribed stool softener.

Answer and Explanation

The Correct Answer is D

A. Administer prescribed PRN sleep medications: While adequate rest is important for postpartum recovery, it does not address the immediate risk to the client’s healing perineal tissue and comfort related to the fourth-degree laceration.

B. Encourage use of prescribed analgesic perineal sprays: Pain management is important for comfort and mobility, but it does not prevent complications such as wound disruption or trauma during defecation, which could impair healing.

C. Encourage breastfeeding to promote uterine involution: Breastfeeding supports uterine contraction and reduces postpartum bleeding, but it does not directly impact the care and protection of a severe perineal laceration.

D. Administer prescribed stool softener: Preventing straining during bowel movements is critical in promoting healing of a fourth-degree perineal laceration. Stool softeners reduce the risk of trauma to the repaired tissue, prevent pain, and minimize potential complications such as wound dehiscence.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Ask the client about gastrointestinal pain: PPIs reduce gastric acid secretion, which relieves symptoms such as heartburn, epigastric pain, and discomfort related to peptic ulcer disease or GERD. Assessing the client’s report of pain evaluates whether the medication is effective.

B. Auscultate for bowel sounds in all quadrants: Bowel sounds indicate gastrointestinal motility rather than acid suppression. PPIs do not directly affect peristalsis, so auscultation is not a reliable measure of drug effectiveness.

C. Measure the client's fluid intake and output: Fluid balance is important in overall patient care but is not a direct indicator of how well a PPI is working. Intake and output monitoring is more relevant to renal or fluid management.

D. Monitor the client's serum electrolyte levels: Electrolyte monitoring may be necessary with prolonged PPI therapy due to risks such as hypomagnesemia, but it does not provide immediate information on short-term medication effectiveness.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

Rationale for correct choices:

• Respirations: Morphine is an opioid analgesic that can depress the respiratory center in the brainstem, leading to slowed breathing and hypoventilation. Monitoring respirations after administration is critical to detect early signs of opioid-induced respiratory depression.

• Ice application to the shoulder: Applying ice reduces swelling, pain, and inflammation by causing vasoconstriction and limiting fluid accumulation at the injury site. For an acute humeral fracture with significant swelling and bruising, cold therapy is the appropriate intervention.

Rationale for incorrect choices:

• Nausea: While morphine can cause nausea and vomiting as side effects, they are not the most life-threatening concerns compared to respiratory depression. Monitoring nausea is appropriate but not the priority when evaluating opioid safety.

• Blood pressure: Morphine can cause hypotension, but this effect is less common and typically secondary to respiratory depression and vasodilation. Continuous monitoring of blood pressure is helpful, but respiratory monitoring takes priority in detecting opioid complications.

• Early active range of motion: Active movement of the injured arm is not recommended immediately after a displaced humeral fracture, as it can worsen displacement and interfere with healing. Immobilization and stabilization are required before introducing range-of-motion exercises.

• Heat application to the shoulder: Heat increases blood flow to tissues, which can worsen swelling and bleeding in the acute phase of injury. Applying heat too soon after a fracture increases the risk of complications rather than reducing them.

View Question and Answer

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

The nurse is planning care for a client who has a fourth degree midline laceration that occurred during vaginal delivery of an 8-pound 10-ounce (3674 grams) infant. Which intervention has the highest priority for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

Correct Answer is A

Explanation

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain?

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse?

A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

When performing suctioning for a client with a tracheostomy, which action should the nurse include?

Patient Data Exhibits The nurse is reviewing the client's initial assessment findings. Which assessment findings require follow-up? Select all that apply.

Patient Data Exhibits Which of the following findings should the nurse recognize as manifestations of digoxin toxicity? (Select all that apply.)

An older adult client is referred to a rehabilitation facility following a cerebrovascular accident (CVA).The client is aphasic with left sided paresis and is having difficulty swallowing. Which intervention is most important for the nurse to include in the client's plan of care?

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.