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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Iodine: An iodine allergy is more relevant for clients receiving contrast media or iodine-based antiseptics, not dorzolamide. Dorzolamide is a carbonic anhydrase inhibitor, and its risk profile is not associated with iodine sensitivity.

B. Latex: Latex allergy is an important consideration in nursing care, particularly regarding equipment and supply use. However, dorzolamide as an ophthalmic preparation does not contain latex, so this allergy does not directly influence the safety of administering the drug.

C. Penicillin: Penicillin allergy is significant for antibiotics, but dorzolamide is not a beta-lactam or related medication. There is no cross-reactivity between penicillin and carbonic anhydrase inhibitors, making this allergy less concerning for this prescription.

D. Sulfonamide: Dorzolamide contains a sulfonamide component, and clients with a sulfonamide allergy are at risk for hypersensitivity reactions such as rash, conjunctivitis, or even systemic effects. Reviewing the medical record for a sulfonamide allergy is essential before administration to prevent serious complications.

A. Position the client's head facing away from the site. B. Aspirate for the presence of a blood return. C. Prepare a saline flush in a three mL syringe. D. Initiate an infusion of 0.9% normal saline solution.

Correct Answer is B

Explanation

A. Position the client's head facing away from the site: While positioning can help reduce the risk of infection or discomfort, it does not ensure that the catheter is patent or safe for medication administration.

B. Aspirate for the presence of a blood return: Confirming blood return verifies that the central venous catheter is patent and correctly positioned in the bloodstream. This is a critical safety step before administering intravenous medications to prevent extravasation or ineffective delivery.

C. Prepare a saline flush in a three mL syringe: While flushing the catheter is important for maintaining patency, the nurse must first confirm the catheter is patent by aspirating for blood return before flushing or administering medication.

D. Initiate an infusion of 0.9% normal saline solution: Starting a continuous infusion is not necessary solely for medication administration. The priority is confirming patency and safe access, after which flushing and medication administration can proceed.

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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

A client diagnosed with glaucoma receives a new prescription for dorzolamide. Prior to administering the medication, the nurse should review the electronic medical record for which allergy?

Correct Answer is D

Explanation

When preparing to administer an intravenous medication through a client's triple lumen central venous catheter, the nurse observes that there are no continuous intravenous fluids infusing. Which action should the nurse take?

Correct Answer is B

Explanation

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