A nurse is caring for a client who is 12 hours postpartum and has a fourth-degree laceration of the perineum. The nurse should take which of the following actions?
Provide the client with a cool sitz bath.
Administer methylergonovine 0.2 mg IM.
Apply povidone-iodine to the client's perineum after she voids.
Apply a moist, warm compress to the perineum.
The Correct Answer is D
A fourth-degree laceration involves a tear that extends through the perineal muscles and extends to the anal sphincter. This type of laceration requires careful management to promote healing and prevent infection. Applying a moist, warm compress to the perineum helps to promote blood flow, reduce swelling, and provide comfort to the client.
Option a) Providing the client with a cool sitz bath is not appropriate for a fourth-degree laceration. Cool sitz baths are typically used for relieving discomfort and reducing swelling in cases of perineal trauma, but in the case of a fourth-degree laceration, warm compresses are preferred.
Option b) Administering methylergonovine 0.2 mg IM is not necessary for a fourth-degree laceration. Methylergonovine is a medication used to promote uterine contractions and prevent postpartum hemorrhage. However, it is not specifically indicated for the management of perineal lacerations.
Option c) Applying povidone-iodine to the client's perineum after she voids is not recommended for a fourth-degree laceration. Povidone-iodine is an antiseptic solution used to disinfect the skin. However, it is not typically used on open wounds, such as perineal lacerations, as it may delay wound healing.
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Related Questions
Correct Answer is D
Explanation
Neonatal abstinence syndrome (NAS) occurs in newborns who were exposed to addictive substances, such as opioids, during pregnancy. Infants with NAS may experience withdrawal symptoms and can be hypersensitive to stimuli. Therefore, it is important to minimize unnecessary handling to help reduce stimulation and discomfort for the newborn.
Option a) Swaddling the newborn with his legs extended may increase discomfort for a newborn with NAS. It is often recommended to swaddle newborns with NAS in a flexed position to provide a sense of security and comfort.
Option b) Maintaining eye contact during feedings may be overwhelming for a newborn with NAS. Maintaining a calm, quiet environment during feedings can help reduce overstimulation and improve feeding success.
Option c) Scheduling larger volume feedings at less frequent intervals may not be appropriate for a newborn with NAS. These infants may have poor feeding tolerance and may benefit from smaller, more frequent feedings to avoid overwhelming their gastrointestinal system.
Therefore, option d) Plan care to minimize handling of the newborn is the correct action to take when caring for a newborn with neonatal abstinence syndrome. It helps reduce stimulation and discomfort for the newborn.
Correct Answer is D
Explanation
A newborn who is 1 hour old and has a respiratory rate of 50/min, a heart rate of 130/min, and an axillary temperature of 36.1°C (97°F) has normal vital signs for their age¹². However, the newborn is at risk of losing heat and developing hypothermia, which can cause serious complications such as hypoglycemia, metabolic acidosis, and respiratory distress³. Therefore, the nurse should take measures to prevent heat loss and maintain a neutral thermal environment for the newborn³⁴.
One of the effective ways to prevent heat loss in newborns is to apply a cap to their head. The head has a large surface area relative to the body mass and can account for up to 50% of heat loss in newborns³⁴. A cap can reduce heat loss through radiation, convection, and evaporation from the scalp³⁴. The cap should be dry, clean, and snug-fitting, and should not cover the eyes or ears of the newborn³⁴.
a) Giving the newborn a warm bath is not an appropriate action for the nurse to take. Bathing can increase heat loss through evaporation and conduction, especially if the water temperature is not optimal or the room temperature is too low³⁴. Bathing should be delayed until the newborn's temperature is stable and preferably after the first breastfeeding session³⁴.
b) Repositioning the newborn is not a sufficient action for the nurse to take. Repositioning may help reduce heat loss through conduction if the newborn is placed away from cold surfaces or objects, but it does not address heat loss through other mechanisms³⁴. Repositioning should be combined with other interventions, such as skin-to-skin contact, swaddling, or radiant warmers³⁴.
c) Obtaining an oxygen saturation level is not a relevant action for the nurse to take. Oxygen saturation is a measure of how much oxygen is carried by the hemoglobin in the blood. It is not directly related to temperature regulation or heat loss in newborns³⁴. Oxygen saturation should be monitored routinely in all newborns before discharge as part of screening for congenital heart disease, but it does not address the risk of hypothermia⁵.
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