A nurse is caring for a client who has unrelieved episiotomy pain 8 hr following delivery. Which of the following actions should the nurse take?
Place a soft pillow under the client's buttocks.
Apply an ice pack to the perineum.
Position a heating lamp toward the episiotomy.
Prepare a warm sitz bath.
The Correct Answer is B
The correct answer is choice B: Apply an ice pack to the perineum. This is the recommended action for unrelieved episiotomy pain within the first 24 hours following delivery, as it helps reduce swelling and provide pain relief.
Choice A rationale:
Placing a soft pillow under the client’s buttocks may provide comfort, but it does not directly address the inflammation and pain associated with an episiotomy. It is not the primary intervention for unrelieved episiotomy pain shortly after delivery.
Choice B rationale:
Applying an ice pack to the perineum is a standard practice for reducing pain and swelling after an episiotomy. The cold temperature causes vasoconstriction, which can help to decrease swelling and provide pain relief. This is especially effective within the first 24 hours post-delivery.
Choice C rationale:
Positioning a heating lamp toward the episiotomy is not recommended immediately following the procedure, as heat can increase blood flow to the area, potentially worsening swelling and pain in the acute phase after the surgery.
Choice D rationale:
While a warm sitz bath may be beneficial for episiotomy pain relief, it is typically recommended after the initial 24-hour period post-delivery. In the first 24 hours, cold therapy is preferred to reduce acute inflammation and pain.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Fetal head compression is unlikely to cause variable decelerations in the fetal heart rate. During contractions and labor, the fetal head may experience pressure, but this usually leads to early decelerations, not variable decelerations. Early decelerations are considered benign and are caused by the head's pressure stimulating the vagus nerve, resulting in a temporary decrease in heart rate.
Choice B rationale:
nature.
Choice C rationale:
Maternal opioid administration is not a direct cause of variable decelerations in the fetal heart rate. While opioids can cross the placenta and may affect the fetus, they are more likely to cause other issues, such as respiratory depression in the newborn, rather than variable decelerations.
Choice D rationale:
Uteroplacental insufficiency is not the primary factor causing variable decelerations. Uteroplacental insufficiency refers to an inadequate blood flow and oxygen delivery to the placenta, which c
Correct Answer is B
Explanation
Choice A reason:
Initiating epidural anesthesia too soon may delay rupture of fetal membranes. This statement is not accurate. Epidural anesthesia itself does not have a direct impact on the rupture of fetal membranes. The timing of rupturing membranes is determined based on the progress of labor and other clinical indications. There is no causal relationship between epidural anesthesia and the timing of membrane rupture.
Choice B reason:
Initiating epidural anesthesia too soon can prolong labor. This statement is correct. Epidural anesthesia, while providing pain relief during labor, can also cause some degree of motor blockage and decrease the woman's ability to push effectively. This can potentially lead to a lengthening of the labor process. It is generally recommended to wait until a good labor pattern has been established to avoid unnecessary prolongation of labor.
Choice C reason:
Initiating epidural anesthesia too soon can cause fetal depression. This statement is not entirely accurate. Epidural anesthesia can cross the placenta and reach the fetus, but the effect on the baby is usually minimal. However, fetal monitoring is essential during labor to ensure the baby's well-being, regardless of whether epidural anesthesia is used or not.
Choice D reason:
Initiating epidural anesthesia too soon can cause maternal hypertension. This statement is not supported by evidence. Epidural anesthesia does not typically cause maternal hypertension. It can, however, lead to a decrease in blood pressure in some cases, which is why careful monitoring of maternal blood pressure is necessary during and after the administration of epidural anesthesia.
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