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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

Protamine sulfate is an antidote for heparin overdose and should be administered slowly intravenously to avoid rapid hemodynamic changes and potential adverse reactions.Administering it within 30 minutes ensures timely reversal of heparin’s anticoagulant effects.

Choice B rationale:

Administering protamine sulfate rapidly intramuscularly is incorrect because intramuscular administration is not recommended due to the risk of hematoma formation and slower absorption compared to intravenous administration.

Choice C rationale:

While slow intravenous administration is correct, the timing of 60 minutes is less effective compared to 30 minutes for reversing heparin’s effects promptly.

Choice D rationale:

Rapid intramuscular administration is incorrect for the same reasons as Choice B.Rapid administration can cause adverse reactions, and intramuscular administration is not the preferred route.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Explanation

Choice A rationale:

A pH level of 7.35 to 7.45 and HCO3- level of 22 to 26 mEq/L indicate a resolution of ketoacidosis. The normal pH range for the body is 7.35 to 7.45, and a return to this range indicates that the body’s acid-base balance has been restored. The bicarbonate (HCO3-) level is a measure of the metabolic component of the body’s acid-base balance, and the normal range is 22 to 26 mEq/L. A return to this range indicates that the metabolic acidosis caused by the ketoacidosis has been resolved.

Choice B rationale:

A pH level of 7.25 to 7.35 and HCO3- level of 18 to 22 mEq/L would indicate that the client is still in a state of mild acidosis, as the pH is below the normal range and the bicarbonate level is also slightly low, indicating a metabolic acidosis.

Choice C rationale:

A pH level of 7.15 to 7.25 and HCO3- level of 14 to 18 mEq/L would indicate a moderate acidosis. Both the pH and bicarbonate levels are significantly below their normal ranges, indicating a significant disruption in the body’s acid-base balance.

Choice D rationale:

A pH level of 7.05 to 7.15 and HCO3- level of 10 to 14 mEq/L would indicate severe acidosis, which would be life-threatening if not corrected. Both the pH and bicarbonate levels are far below their normal ranges, indicating a severe disruption in the body’s acid-base balance. In conclusion, choice A is correct because it represents values within the normal ranges for both pH and bicarbonate, indicating a resolution of ketoacidosis.

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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?

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What are some important nursing considerations for this medication? *.

Correct Answer is A

Explanation

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Explanation

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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?