Which nursing diagnosis identified on a patient's nursing care ...

[JGIBBSON]

Which nursing diagnosis identified on a patient's nursing care plan has the highest priority during oxytocin administration?
 
  a. Fear related to unknown outcome
  b. Potential for altered uterine tissue perfusion related to uterine contractions
  c. Pain related to uterine contractions
  d. Knowledge deficit related to the use of oxytocin during labor

Question 2

What is characteristic of third-degree perineal lacerations?
 
  a. Extends into the mucous membrane
  b. Extends into the muscles of the perineal body
  c. Extends through the rectal mucosa into the anterior wall of the rectum
  d. Extends into the anal sphincter

[paavo]

Answer to Question 1

ANS: B
Although all nursing diagnoses are applicable in this situation, the potential for altered uterine tissue perfusion is the highest priority. During oxytocin administration, the nurse must carefully monitor frequency, duration, and intensity of uterine contractions because overstimulation can cause decreased uterine perfusion, jeopardizing fetal oxygenation.

Answer to Question 2

ANS: D
Perineal lacerations are categorized by the following:
 First degree: extends through the skin and in the mucous membrane.
 Second degree: extends through the skin and mucous membrane and into the muscles of the perineal body.
 Third degree: involves the skin, mucous membrane, muscles of the perineal body, and the anal sphincter.
 Fourth degree: extends through the rectal mucosa into the anterior wall of the rectum.
If lacerations of the perineum occur during delivery, they are classified in one of four degrees, depending on severity of the tear.