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.

Administer prescribed stool softener.

Encourage breastfeeding to promote uterine involution.

Answer and Explanation

The Correct Answer is C

The correct answer is choice c. Administer prescribed stool softener.

Choice A rationale:

Administering prescribed PRN sleep medications can help the client rest, but it is not the highest priority. Managing pain and preventing complications from the laceration are more critical.

Choice B rationale:

Encouraging the use of prescribed analgesic perineal sprays can help manage pain and promote healing, but it is not as crucial as preventing constipation, which can cause significant discomfort and complications.

Choice C rationale:

Administering prescribed stool softeners is the highest priority because a fourth-degree laceration involves the anal sphincter and rectal mucosa. Preventing constipation is essential to avoid straining during bowel movements, which can cause pain and disrupt the healing process.

Choice D rationale:

Encouraging breastfeeding to promote uterine involution is important for postpartum recovery, but it is not directly related to the care of a fourth-degree laceration. Managing pain and preventing complications from the laceration take precedence.

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Correct Answer is D

Explanation

Choice A rationale:

Continue with the blood pressure assessment. Continuing with the blood pressure assessment without addressing the observed auscultatory gap could lead to an inaccurate reading. It's important to investigate and note the presence of an auscultatory gap before proceeding with the assessment.

Choice B rationale:

Reposition the stethoscope over the brachial artery. Repositioning the stethoscope may not resolve the issue of hearing silence followed by a Korotkoff sound. It is important to assess the situation further before making adjustments.

Choice C rationale:

Reinflate the cuff to a higher number. Reinflating the cuff to a higher number without addressing the auscultatory gap can result in an inaccurate reading. The presence of an auscultatory gap should be noted and managed appropriately.

Choice D rationale:

Note the presence of an auscultatory gap. This is the correct choice. An auscultatory gap is a temporary disappearance of sounds during the blood pressure measurement, and it may indicate underlying cardiovascular issues. The nurse should note its presence, document it, and take appropriate action if necessary.

Correct Answer is ["30"]

Explanation

The correct answer is 30 mL/hour.

Step 1 is to calculate the total amount of norepinephrine in the IV bag: 4 mg norepinephrine ÷ 1000 mL = 0.004 mg/mL

Step 2 is to convert the patient's weight from pounds to kilograms: 176 pounds ÷ 2.2 = 80 kilograms

Step 3 is to calculate the total amount of norepinephrine the patient will receive per minute: 2 mcg/min × 60 min = 120 mcg/min

Step 4 is to convert micrograms (mcg) to milligrams (mg): 120 mcg ÷ 1000 = 0.12 mg

Step 5 is to calculate the total volume of norepinephrine needed per hour: 0.12 mg ÷ 0.004 mg/mL = 30 mL/hour

Therefore, the nurse should program the infusion pump to deliver 30 mL/hour.

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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

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

Correct Answer is D

Explanation

A client who weighs 176 pounds receives a prescription for norepinephrine 2 mcg/min intravenously (IV). The IV bag is labeled, "Norepinephrine 4 mg in dextrose 5% in water (D;W) 1,000 mL." How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.).

Correct Answer is ["30"]

Explanation

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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?