Difficulty: Medium
Average Score: 75%
Simulated
The postpartum client suffered a fourth-degree perineal laceration during her vaginal birth. Which interventions should the nurse add to the clientÔÇÖs plan of care? Select all that apply.
Correct answer
C,E
Rationale
Activity should be increased, not decreased, to reduce the potential for constipation. Fluids should be increased, not decreased, to reduce the potential for dehydration and constipation. The client with a fourth-degree perineal laceration should be instructed to increase dietary fiber to help maintain bowel continence and decrease perineal trauma from constipation. A perineal laceration will not affect the condition of the uterus; there is no need to increase uterine monitoring. The client with a fourth-degree perineal laceration should be given a stool softener bid to help maintain bowel continence and decrease perineal trauma from constipation.