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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?
- A. Apply a moist, warm compress to the perineum.
- B. Provide the client with a cool sitz bath.
- C. Administer methylergonovine 0.2 mg IM.
- D. Apply povidone-iodine to the client’s perineum after she voids.
Correct Answer: A
Rationale: Correct Answer: A. Apply a moist, warm compress to the perineum.
Rationale: Applying a moist, warm compress helps reduce pain, swelling, and discomfort in the perineal area postpartum. It promotes healing and provides comfort to the client with a fourth-degree laceration. This action also helps improve circulation to the area, aiding in the healing process.
Incorrect Choices:
B: Providing a cool sitz bath may provide relief for hemorrhoids or perineal discomfort but is not the best option for a fourth-degree laceration. Warm compresses are more suitable in this situation.
C: Administering methylergonovine is used to prevent or treat postpartum hemorrhage, not for perineal lacerations.
D: Applying povidone-iodine after voiding is not recommended as it can be irritating to the wound and delay healing.
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A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
- A. Vaginal candidiasis
- B. Abdominal distention
- C. Afterpains
- D. Third-degree perineal laceration
Correct Answer: D
Rationale: The correct answer is D: Third-degree perineal laceration. Using a suppository in a client with a third-degree perineal laceration can potentially worsen the injury and increase the risk of infection. The suppository insertion may cause trauma to the already compromised tissue, leading to further complications. It is crucial to avoid any interventions that can exacerbate the injury and hinder the healing process. Choices A, B, and C are not contraindications to using a suppository. Vaginal candidiasis, abdominal distention, and afterpains do not directly impact the safety or effectiveness of using a suppository in this scenario.
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 105/64 mm Hg
- B. Heart rate 98/min
- C. Urine output of 280 mL within 8 hr
- D. Urine negative for ketones
Correct Answer: D
Rationale: The correct answer is D: Urine negative for ketones. In hyperemesis gravidarum, excessive vomiting can lead to dehydration and ketosis. A negative urine ketone result indicates the client may not be adequately hydrated or receiving proper nutrition. This finding should be reported to the provider for further evaluation and intervention. Option A (Blood pressure 105/64 mm Hg) is within normal range for a pregnant woman. Option B (Heart rate 98/min) is slightly elevated but may be due to dehydration. Option C (Urine output of 280 mL within 8 hr) is inadequate and indicates poor fluid intake or excessive fluid loss. Reporting a negative urine ketone result is crucial to prevent further complications.
A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?
- A. "The nurse will carry your baby in their arms to the nursery for scheduled procedures."
- B. "We will document the relationship of visitors in your medical record."
- C. "It's okay for your baby to sleep in the bed with you while in the hospital."
- D. "Staff members who take care of your baby will be wearing a photo identification badge."
Correct Answer: D
Rationale: The correct answer is D: "Staff members who take care of your baby will be wearing a photo identification badge." This statement promotes security and safety by ensuring that only authorized personnel are handling the newborn. It helps prevent unauthorized individuals from accessing the baby. The photo identification badge serves as visual confirmation of the staff members' credentials and authority. This measure enhances the client's peace of mind and trust in the healthcare team.
Other choices are incorrect:
A: Carrying the baby to the nursery for procedures may not guarantee security as it could expose the baby to unnecessary risks.
B: Documenting visitor relationships is important but does not directly address the safety and security of the newborn.
C: Sharing a bed with the baby can increase the risk of accidental suffocation or other sleep-related risks.
Overall, choice D is the most direct and effective way to ensure the security and safety of the newborn.
A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Frequent vomiting with weight loss of 3 lb in 1 week
- B. Reports of mood swings
- C. Nosebleeds occurring approximately 3 times per week
- D. Increased vaginal discharge
Correct Answer: A
Rationale: The correct answer is A: Frequent vomiting with weight loss of 3 lb in 1 week. This finding is concerning as it may indicate hyperemesis gravidarum, a severe form of morning sickness that can lead to dehydration and electrolyte imbalances, posing a risk to both the mother and fetus. The weight loss is significant and needs immediate attention from the provider to prevent complications.
B: Reports of mood swings are common in pregnancy due to hormonal changes and are not typically a cause for immediate concern.
C: Nosebleeds occurring approximately 3 times per week are often due to increased blood volume and hormone changes during pregnancy and are not considered a serious issue unless they are severe or frequent.
D: Increased vaginal discharge is a common symptom of pregnancy and is usually not a cause for alarm unless accompanied by other symptoms like itching or a foul odor.
A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase intake of vitamin B12. Which of the following foods should the nurse recommend?
- A. Fortified soy milk
- B. Raw carrots
- C. Fresh citrus fruits
- D. Brown rice
Correct Answer: A
Rationale: The correct answer is A: Fortified soy milk. Vitamin B12 is mainly found in animal products, making it challenging for vegans to obtain sufficient amounts. Fortified soy milk is a great source of vitamin B12 for vegans. Raw carrots (B), fresh citrus fruits (C), and brown rice (D) do not contain significant amounts of vitamin B12. It is important for the nurse to recommend a food source that is rich in vitamin B12 to help the client meet their nutritional needs.