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.

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Correct Answer is B

Explanation

A. Intubation tray: An intubation tray is necessary if the client experiences airway compromise or respiratory failure, but it does not directly address complications from an ineffective thoracentesis, such as persistent pneumothorax or pleural effusion.

B. Chest tube insertion tray: If the thoracentesis is ineffective and the pleural space continues to fill or air accumulates, a chest tube may be required to drain fluid or air and re-expand the lung. Having a chest tube tray ready ensures rapid intervention for these potential complications.

C. Crash cart: A crash cart is essential for emergencies involving cardiac or respiratory arrest, but it is not the first-line equipment for an ineffective thoracentesis unless the client acutely decompensates.

D. Ventilator: Mechanical ventilation may be required for severe respiratory failure, but it is not an immediate bedside intervention for an unsuccessful thoracentesis. The priority is to remove fluid or air from the pleural space.

A. Place a warm blanket on the client. B. Administer IV fluids per protocol. C. Review the medication administration record. D. Check the urinary catheter r an occlusion.

Correct Answer is B

Explanation

A. Place a warm blanket on the client: Providing warmth may improve comfort temporarily but does not address the underlying cause of the client’s cool, moist hands, prolonged capillary refill, or low urine output, which suggest possible hypovolemia or shock.

B. Administer IV fluids per protocol: The client’s signs restlessness, cool clammy skin, prolonged capillary refill, and low urine output indicate hypoperfusion likely due to fluid deficit. Administering IV fluids promptly helps restore circulating volume and tissue perfusion.

C. Review the medication administration record: While medication review is important for overall safety, it does not address the immediate risk of hypovolemic shock or low urine output in this client.

D. Check the urinary catheter for an occlusion: Although checking for blockage is reasonable if a catheter is present, the client’s overall clinical presentation points to systemic hypovolemia rather than a localized urinary obstruction.

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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

The nurse is assisting the healthcare provider with a thoracentesis for a client who has emphysema. Which equipment should the nurse have at the bedside in the event the procedure is ineffective?

Correct Answer is B

Explanation

The nurse is caring for a postoperative client who has a saline lock and minimal urine in the drainage bag, who appears anxious and restless. The nurse notices that the client's hands are cool and moist, with prolonged capillary refill. Which action should the nurse take?

Correct Answer is B

Explanation

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