A nurse is caring for a client who has unrelieved episiotomy pain 8 hours following delivery. Which of the following actions should the nurse take? (Select onE.:
Place a soft pillow under the client's buttocks.
Prepare a warm sitz batH.
Position a heating lamp toward the episiotomy.
Apply an ice pack to the perineum.
The Correct Answer is D
Choice A: Placing a soft pillow under the client's buttocks is not an effective action, as it can increase the pressure and the swelling on the perineal area and worsen the pain. The nurse should avoid placing anything under the client's buttocks and encourage the client to lie on the side or sit on a firm surfacE.
Choice B: Preparing a warm sitz bath is not an appropriate action, as it can increase the blood flow and the inflammation on the perineal area and worsen the pain. The nurse should avoid using heat on the perineum for the first 24 hours after delivery and use cold therapy insteaD.
Choice C: Positioning a heating lamp toward the episiotomy is not an appropriate action, as it can cause burns and infections on the perineal area and worsen the pain. The nurse should avoid using heat on the perineum for the first 24 hours after delivery and use cold therapy insteaD.
Choice D: Applying an ice pack to the perineum is an effective action, as it can reduce the blood flow and the inflammation on the perineal area and relieve the pain. The nurse should apply an ice pack wrapped in a towel or a disposable cold pack to the perineum for 10 to 20 minutes every 2 to 4 hours for the first 24 hours after delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A: Amniotic fluid in the vaginal vault indicates that the client's membranes have ruptured, which is a sign of labor. The fluid should be clear and odorless. The nurse should assess the fetal heart rate and monitor for signs of infection or cord prolapsE.
Choice B: Pain just above the navel is not a sign of labor. It may indicate other conditions such as gastritis, gallstones, or pancreatitis. The pain of labor is usually felt in the lower back and abdomen and radiates to the thighs.
Choice C: Cervical dilation is a sign of labor. It indicates that the cervix is opening and thinning to allow the passage of the fetus. The nurse should measure the cervical dilation in centimeters and document the progress of labor.
Choice D: Contractions every 3 to 4 minutes are a sign of labor. They indicate that the uterus is contracting and pushing the fetus downwarD. The nurse should assess the frequency, duration, and intensity of the contractions and monitor the fetal responsE.
Correct Answer is D
Explanation
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.