A nurse is caring for a client who had a vaginal birth 2 hr ago and has soaked two perineal pads in the past 30 min. Which of the following actions should the nurse take?

Assist the client to a sitz bath.

Assess the client's uterine tone.

Encourage the client to breastfeed.

Apply an ice pack to the client's perineum.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Assisting the client to a sitz bath is not the priority action in this situation. The client has soaked two perineal pads in the past 30 minutes, indicating excessive bleeding, which requires immediate attention.

Choice B rationale:

Assessing the client's uterine tone is essential to determine if the uterus is contracting appropriately. Uterine atony, where the uterus fails to contract after childbirth, is a common cause of postpartum hemorrhage. Assessing the tone helps identify this issue and allows for timely interventions.

Choice C rationale:

Encouraging the client to breastfeed may have benefits such as promoting uterine contractions through oxytocin release. However, the priority in this scenario is addressing the potential postpartum hemorrhage.

Choice D rationale:

Applying an ice pack to the client's perineum may provide comfort, but it does not address the concerning symptom of excessive bleeding and potential postpartum hemorrhage.

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Correct Answer is C

Explanation

Choice A rationale:

Fentanyl is an opioid analgesic and is not used to counteract the effects of meperidine in the newborn. Both fentanyl and meperidine are opioids, and using fentanyl in this context would not counteract the effects of meperidine.

Choice B rationale:

Flumazenil is a medication used to reverse the effects of benzodiazepines, not opioids like meperidine. It is not appropriate for countering the effects of meperidine in the newborn.

Choice C rationale:

Naloxone is an opioid antagonist that can reverse the effects of opioids like meperidine. When a newborn has been exposed to opioids during labor, such as meperidine given to the mother, there is a risk of respiratory depression in the newborn. Naloxone can quickly reverse this effect and restore normal respiratory function.

Choice D rationale:

Benztropine is an anticholinergic medication used to treat side effects of antipsychotic drugs and is not relevant in this situation. It would not counteract the effects of meperidine on the newborn.

A. True. B. False.

Correct Answer is A

Explanation

Fresh cabbage leaves have been traditionally used as a home remedy to help alleviate pain and discomfort associated with breast engorgement. The coolness of the cabbage leaves can provide a soothing effect, and they may also have anti-inflammatory properties that help reduce swelling. However, it is important to note that this should be used as a complementary measure and not a substitute for medical treatment or advice if the engorgement is severe or persistent.

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A nurse is caring for a client who had a vaginal birth 2 hr ago and has soaked two perineal pads in the past 30 min. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A laboring client received meperidine IV one hour prior to delivery. Which of the following medications should the nurse have available to counteract the effects of this medication on the newborn?

Correct Answer is C

Explanation

True or False. For breast engorgement, do fresh cabbage leaves placed inside the bra can help alleviate pain associated with breast engorgement?

Correct Answer is A

Explanation

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