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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Offer to discuss the client's health status with each of the adult children: While involving family in discussions is important, the immediate question from the spouse is about recognizing signs of imminent death. Directly explaining the physiological changes is more appropriate at this moment.
B. Reassure the spouse that the healthcare provider (HCP) will notify when to call the children: Waiting for the HCP to give a signal does not provide the spouse with the knowledge they are seeking. It may delay preparation and increase anxiety during the final hours.
C. Gather information regarding how long it will take for the children to arrive: While logistical planning is helpful, it does not address the spouse’s question about recognizing imminent death and understanding what to expect.
D. Explain that the client will start to lose consciousness and the body systems will slow down: Providing clear, compassionate information about the expected signs of dying helps the spouse recognize that death is near, allows family members to prepare emotionally, and facilitates meaningful final interactions with the client.
Correct Answer is ["A","B","D","E"]
Explanation
A. Use a picture of a clock to indicate the dose times: Visual aids help parents with limited literacy or cognitive challenges understand when to give medications, improving adherence and safety.
B. Mark the dose on the syringe using color-coded tape: Color-coded markings provide a clear, simple guide for accurate dosing, reducing the risk of errors.
C. Instruct them to add the medication to formula or juice: Mixing medications with food or drink can alter absorption, interfere with effectiveness, or result in incomplete ingestion. This practice is generally discouraged unless specifically approved by the healthcare provider.
D. Place a color code on the medication containers: Color-coded containers help parents quickly identify the correct medication and dose, supporting safe administration.
E. Schedule medication times with feeding times: Aligning medication administration with regular daily routines such as feeding helps parents remember doses and promotes adherence to the prescribed schedule.
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