A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?
Provide the client with a cool sitz bath.
Administer methylergonovine 0.2 mg IM.
Apply a moist, warm compress to the perineum.
Apply povidone-iodine to the client's perineum after she voids.
The Correct Answer is A
The correct answer is choice a. Provide the client with a cool sitz bath.
Choice A rationale:
A cool sitz bath can help reduce swelling and provide pain relief for a client with a fourth-degree laceration of the perineum. Cooling the area can also help minimize inflammation and promote healing.
Choice B rationale:
Methylergonovine is typically used to prevent or treat postpartum hemorrhage by causing uterine contractions. It is not indicated for the management of perineal lacerations.
Choice C rationale:
Applying a moist, warm compress to the perineum is not recommended immediately postpartum for a fourth-degree laceration, as it can increase swelling and discomfort. Cool treatments are preferred initially.
Choice D rationale:
Applying povidone-iodine to the perineum is not a standard practice for managing perineal lacerations. It can cause irritation and is not necessary for wound care in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A blood glucose level of 110 mg/dL is within the normal range for a non-pregnant individual. During pregnancy, the target range for blood glucose levels may vary, but 110 mg/dL does not typically raise concerns for preeclampsia.
Choice C rationale:
A haemoglobin level of 13 g/dL is within the normal range for a pregnant woman. While haemoglobin levels are important to monitor during pregnancy, this value alone does not indicate a significant concern related to preeclampsia.
Choice D rationale:
Deep tendon reflexes (DTR) of 2+ are within the normal range. Higher DTR levels may be concerning, but a 2+ rating is normal and does not raise immediate alarm for preeclampsia.
Correct Answer is C
Explanation
Choice A rationale:
Scant, bright red spotting during early pregnancy can be a normal finding known as implantation bleeding, which occurs when the embryo attaches to the uterus. It is generally not a cause for concern unless it becomes heavy and is accompanied by severe pain.
Choice B rationale:
Elevated hCG (human chorionic gonadotropin) levels during the first trimester are a normal part of a healthy pregnancy. hCG levels peak around 10-12 weeks of gestation and then gradually decrease. A consistent increase in hCG levels is usually a positive sign of a progressing pregnancy.
Choice C rationale:
Cervical dilation during the first trimester, especially when the client is only at 12 weeks of gestation, is not normal and may indicate an imminent spontaneous abortion (miscarriage). This finding should be reported promptly to the healthcare provider for further assessment and management.
Choice D rationale:
Slight abdominal cramps can be a normal symptom during early pregnancy as the uterus undergoes changes and expands. However, unless they are severe and accompanied by other concerning signs such as heavy bleeding, they are not necessarily indicative of an imminent spontaneous abortion.
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