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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Thromboembolic events are not prevented by methylergonovinE. Thromboembolic events are blood clots that can form in the veins or arteries and cause serious complications such as pulmonary embolism or strokE. Methylergonovine is a uterotonic agent that stimulates the contraction of the uterus and can actually increase the risk of thromboembolic events by causing vasoconstriction and hypertension.
Choice B: Postpartum hemorrhage is prevented by methylergonovinE. Postpartum hemorrhage is excessive bleeding after delivery that can result from uterine atony, retained placenta, or lacerations. Methylergonovine is a uterotonic agent that stimulates the contraction of the uterus and helps control the bleeding by compressing the blood vessels and expelling any placental fragments.
Choice C: Postpartum infection is not prevented by methylergonovinE. Postpartum infection is a bacterial infection that can affect the uterus, the vagina, the bladder, or the breast after delivery. Methylergonovine is a uterotonic agent that has no antibacterial activity and can actually increase the risk of infection by causing fever and chills.
Choice D: Hypertension is not prevented by methylergonovinE. Hypertension is high blood pressure that can cause complications such as preeclampsia, eclampsia, or strokE. Methylergonovine is a uterotonic agent that can actually cause or worsen hypertension by stimulating the alpha-adrenergic receptors and causing vasoconstriction.
Correct Answer is D
Explanation
Choice A: Increasing IV fluid rate is a secondary action, as it helps restore the blood volume and improve the blood pressure and the fetal perfusion. The nurse should perform this action after taking the first action.
Choice B: Elevating the legs is a tertiary action, as it helps increase the venous return and the cardiac output and improve the blood pressure and the fetal perfusion. The nurse should perform this action after taking the first and second actions.
Choice C: Notifying the provider is a quaternary action, as it helps communicate the situation and obtain further orders and interventions. The nurse should perform this action after taking the first, second, and third actions.
Choice D: Placing the client in a lateral position to relieve pressure on the inferior vena cava is the first and most important action, as it helps prevent or correct the hypotension and the fetal bradycardia caused by the epidural anesthesia block. The epidural anesthesia block can block the sympathetic nerve fibers and cause vasodilation and pooling of blood in the lower extremities, which can reduce the blood pressure and the placental perfusion. The pressure of the gravid uterus on the inferior vena cava can also reduce the venous return and the cardiac output, which can worsen the hypotension and the fetal bradycardiA. By placing the client in a lateral position, the nurse can reduce the pressure on the inferior vena cava and improve the blood flow and the oxygen delivery to the fetus.
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