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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choicec. 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.
Correct Answer is D
Explanation
The correct answer is choice d. Activate the lockdown procedure.
Choice A rationale:
Asking the mother if any visitors were expected to arrive is important for gathering information, but it is not the immediate priority when a newborn is missing. The primary concern is to ensure the safety and security of the infant.
Choice B rationale:
Matching ID bands of all infants and mothers on the unit is a crucial step in verifying the identity of the newborn, but it should be done after ensuring that the unit is secure and the baby cannot be taken out of the facility.
Choice C rationale:
Determining if the newborn is in the nursery is also important, but it should be done after securing the unit to prevent any potential abduction.
Choice D rationale:
Activating the lockdown procedure is the first and most critical action. This ensures that all exits are secured, preventing anyone from leaving the unit with the infant. It is a safety measure to protect the newborn and is the immediate priority in such situations.
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