Which of the following nursing interventions will promote comfort for a client with a labial first degree laceration? Select all that apply.

A. The woman has a laceration:
The orders for perineal ice packs, sitz baths, and a stool softener suggest that the woman may have sustained perineal trauma, such as a laceration, during childbirth. Ice packs are used initially to reduce swelling and discomfort, while a sitz bath helps with healing and soothing of the perineal area. Stool softeners are prescribed to prevent straining during bowel movements, which could worsen the discomfort of a laceration. These interventions are commonly recommended for women who experience perineal lacerations during vaginal delivery.

B. The woman had her fourth baby:
While the fact that this is the woman’s fourth pregnancy may influence her overall recovery, it is not directly correlated with the orders for ice packs, sitz baths, and stool softeners. Women who have had multiple children may be at a higher risk for perineal trauma due to the stretching of tissues, but this specific care plan is more likely related to a perineal injury, not the number of previous births.

C. The woman received epidural anesthesia:
Epidural anesthesia may be used to manage pain during labor, but it does not directly necessitate the use of ice packs, sitz baths, or stool softeners. While epidurals can sometimes lead to difficulty with bladder or bowel control, they do not typically cause perineal lacerations or require these specific interventions unless there is another issue, such as a laceration, that needs attention.

D. The woman had a vacuum-assisted birth:
Vacuum-assisted births can cause perineal trauma, including lacerations or hematomas, but the order for perineal care (ice packs, sitz baths, stool softeners) is not exclusively linked to vacuum assistance. The woman may have had a laceration during a vacuum-assisted delivery, but it is the laceration itself, rather than the use of the vacuum, that most directly correlates with these interventions. Therefore, the priority care focus is still on addressing the potential for perineal laceration.

A) The vaccine is a live virus and may cause birth defects in the fetus:
The Rubella vaccine is a live attenuated virus, which means it contains a weakened form of the virus. Although this vaccine is safe for most adults, it can cause serious birth defects if a woman becomes pregnant within a 4-week period after receiving the vaccine. The live virus could potentially affect the developing fetus, causing congenital rubella syndrome (CRS), which can result in severe birth defects like heart defects, deafness, and cataracts. To prevent any risk to a future pregnancy, women are advised to wait at least 4 weeks after
vaccination before trying to conceive.

B) Tests to determine if the client developed immunity are not accurate for a month:
This is not accurate. While some tests for rubella immunity can be done soon after vaccination, the primary reason for delaying pregnancy is the live virus in the vaccine, not a delay in testing. The immune response to the vaccine typically develops within a few weeks, but the risk to a fetus comes from the live virus, not the testing process. The 4-week delay is to ensure that the virus has been cleared from the body before pregnancy is attempted.

C) She may have the virus and feel too sick to tolerate a pregnancy:
While the Rubella vaccine can cause mild side effects like fever, it does not typically cause significant illness that would prevent a woman from tolerating a pregnancy. The primary concern is the safety of the fetus, not the mother's symptoms, as any illness is generally mild and transient. The 4-week delay is to prevent potential harm to a fetus due to the live virus present in the vaccine.

D) Her body is not ready to nurture another pregnancy so quickly:
This rationale is not based on any medical guideline. There is no evidence to suggest that the body needs time to "recover" from the Rubella vaccine before becoming pregnant. The reason for the 4-week delay is to ensure that the live virus has been cleared from the body to avoid any risk to a potential pregnancy. The concern is not about the woman's ability to support another pregnancy, but about the potential for the live vaccine virus to harm a developing fetus.