The client delivered vaginally 2 hours ago after receiving an epidural analgesia. She has a slight tingling sensation in both lower extremities, but normal movement. She sustained a second-degree perineal laceration
Her perineum is edematous and ecchymotic. What should the nurse include in the plan of care for this client? 1. Assist the client to the bathroom in 2 hours to void.
2. Place a Foley catheter now.
3. Apply warm packs to the perineum three times a day.
4. Allow the client to rest for the next 8 hours.
1
Explanation: 1. This client is at risk for urinary retention and bladder overdistention. Overdistention occurs postpartum when the woman is unable to empty her bladder, usually because of trauma or the effects of anesthesia. After the effects of anesthesia have worn off, if the woman cannot void, postpartum urinary retention is highly indicative of a urinary tract infection (UTI). Assisting the client to the bathroom is the most likely intervention that will prevent urinary retention.
You might also like to view...
A 32-year-old female patient has a urinary tract infection. Her record reveals that she has recently been treated for anemia. The physician has indicated that drug therapy for the urinary tract infection will last more than 2 weeks
The most important nursing action will be to A) measure the urine pH and check if it is acidic. B) obtain a complete blood count to establish baseline values. C) determine whether the patient should be given medication orally or parenterally. D) measure the patient's blood pressure and heart rate.
A female client is suffering from vaginismus. The nurse is aware that this is a type of:
a. Paraphilia b. Sexual dysfunction c. Psychosexual disorder d. Gender identity disorder
The oldest and most widely used psychoactive drug in the world is
1. Marijuana 2. Heroin 3. Alcohol 4. Cocaine
J.M.'s eCG results show normal sinus rhythm with no stsegment or other changes. you meet with J.M. to formulate a plan of care
Name at least four nutritional interventions. List at least six psychological aspects of the plan of care for J.M.