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.

Answer and Explanation

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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Correct Answer is D

Explanation

Choice D rationale:

The nurse should state, "The purpose of this medication is to boost fetal lung maturity.”. The rationale behind this choice is that betamethasone is a corticosteroid medication commonly administered to women at risk of preterm delivery between 24 and 34 weeks of gestation. Its primary goal is to accelerate fetal lung maturation by promoting the production of surfactant, a substance that coats the lungs and prevents their collapse. By enhancing lung development, the medication helps reduce the risk of respiratory distress syndrome and other respiratory complications that premature infants might face. It does not directly impact fetal heart rate (Choice A), halt cervical dilation (Choice B), or stop preterm labor contractions (Choice C).

Choice A rationale:

The nurse should not state, "The purpose of this medication is to increase the fetal heart rate.”. Betamethasone does not affect the fetal heart rate, as it is primarily used to enhance lung maturity, as mentioned earlier. The incorrect statement may lead to confusion and misunderstanding of the medication's intended purpose.

Choice B rationale:

The nurse should not state, "The purpose of this medication is to halt cervical dilation.”. Betamethasone does not stop or halt cervical dilation. Its main action is on the fetal lungs to promote surfactant production. Cervical dilation is a natural process that occurs during labor and is not influenced by this medication.

Choice C rationale:

The nurse should not state, "The purpose of this medication is to stop preterm labor contractions.”. Betamethasone is not used to stop or prevent preterm labor contractions directly. Instead, its focus is on improving fetal lung maturity to enhance the baby's respiratory function once born prematurely.

A. 7 B. 8 C. 9 D. 10.

Correct Answer is A

Explanation

Step 1 is assessing heart rate. A heart rate of 130/min earns 2 points since a rate above 100/min is optimal.

Step 2 is assessing respiratory effort. A lusty cry earns 2 points as strong crying indicates good respiratory function.

Step 3 is assessing muscle tone. Flexed extremities earn 1 point since full active movement would score 2.

Step 4 is assessing reflex irritability. Grimace when suctioned earns 1 point as a vigorous response (cough, sneeze) would score 2.

Step 5 is assessing color. Acrocyanosis earns 1 point since a fully pink body scores 2.

Final answer: 7

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is A

Explanation

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