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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Related Questions
Correct Answer is C
Explanation
Correct Answer is ["C","D"]
Explanation
Choice A: Applying lotion to the newborn's skin twice per day is not an appropriate action, as it can interfere with the effectiveness of phototherapy and increase the risk of skin irritation and infection. The nurse should avoid using any creams, oils, or lotions on the newborn's skin during phototherapy.
Choice B: Maintaining the newborn in a prone position is not an appropriate action, as it can increase the risk of suffocation and aspiration. The nurse should position the newborn on the back or the side and rotate the position every 2 to 4 hours to expose different areas of the skin to the light.
Choice C: Encouraging the newborn to breastfeed every 2 hours is an appropriate action, as it helps prevent dehydration and maintain adequate nutrition and hydration. The nurse should also monitor the newborn's weight, intake, and output and supplement with formula or intravenous fluids if needeD.
Choice D: Monitoring the newborn's blood glucose level hourly is an appropriate action, as it helps detect and treat hypoglycemia, which can occur due to increased metabolic rate and decreased caloric intakE. The nurse should also monitor the newborn's bilirubin level, hematocrit, and electrolytes and report any abnormal findings.
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