A nurse is caring for a client who is 10 hours postpartum following a vaginal delivery and reports discomfort at the episiotomy site.
Which of the following actions should the nurse take?
Apply witch hazel compresses.
Administer aspirin.
Have the client use a warm pack.
Instruct the client to sit on a soft pillow.
The Correct Answer is A
Choice A rationale
Applying witch hazel compresses (such as Tucks pads) is an effective and preferred action for postpartum perineal discomfort, including episiotomy pain. Witch hazel contains tannins and volatile oils that provide an astringent and anti-inflammatory effect. This action helps to reduce swelling, soothe the tissues, and offer immediate, localized pain relief at the episiotomy site.
Choice B rationale
Administering aspirin (acetylsalicylic acid) for postpartum discomfort is generally contraindicated. Aspirin is a non-steroidal anti-inflammatory drug (NSAID) with antiplatelet effects, which could increase the risk of bleeding postpartum, especially from the placental insertion site or the episiotomy wound. Preferred analgesics are typically acetaminophen or ibuprofen, which have less impact on coagulation.
Choice C rationale
Having the client use a warm pack is not the initial treatment for episiotomy pain within the first 24 hours. Heat promotes vasodilation, which can increase edema and pain in the acutely inflamed and traumatized tissues. Cold therapy (e.g., ice packs) is the standard initial treatment because it causes vasoconstriction, which minimizes swelling and provides a local anesthetic effect.
Choice D rationale
Instructing the client to sit on a soft pillow might seem helpful, but it can sometimes be detrimental. Sitting on a soft, ring-shaped, or inflated pillow can cause the client to press outward on the soft tissues of the perineum, potentially increasing pressure and discomfort on the episiotomy incision. Sitting on a firm surface with the buttocks shifted can be more comfortable for some.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Hypoglycemia in a newborn, defined as a plasma glucose level typically below 40 to 50 mg/dL, starves the central nervous system of its primary energy source, glucose. This lack of fuel in the brain cells often presents with neurological symptoms. Jitteriness (or tremors) is a classic and early neurogenic sign of this metabolic disturbance, resulting from sympathetic nervous system activation.
Choice B rationale
Hypoglycemia typically results in an attempt by the body to conserve energy and may lead to poor peripheral perfusion and decreased metabolic rate, which often manifests as hypothermia (decreased temperature). Increased temperature (hyperthermia) is not a sign of hypoglycemia; instead, it is often associated with infection or environmental overheating.
Choice C rationale
Hypoglycemia causes central nervous system instability and depression, which generally results in a decrease in a newborn's reflexes and muscle tone (hypotonia), or can lead to lethargy and poor feeding. Therefore, brisk reflexes (hyperreflexia) are not a characteristic finding and would suggest other neurological or metabolic conditions.
Choice D rationale
The Moro reflex (or startle reflex) is a complex, primitive reflex that is present and intact in healthy newborns. While severe hypoglycemia can lead to generalized central nervous system depression, which could eventually suppress all reflexes, an absence of a Moro reflex is a more specific sign of a severe neurological injury or a congenital neurological disorder, not a typical early sign of hypoglycemia.
Correct Answer is A
Explanation
Choice A rationale
Elevated maternal serum alpha-fetoprotein (MSAFP) levels can suggest a neural tube defect (NTD), such as spina bifida or anencephaly. Alpha-fetoprotein is a glycoprotein produced by the fetal liver and yolk sac. With an open NTD, this protein leaks from the exposed fetal tissue into the amniotic fluid and subsequently crosses the placenta into the maternal bloodstream, causing the observed elevation.
Choice B rationale
Trisomy 21 (Down syndrome) is typically associated with lower than normal MSAFP levels. MSAFP is part of the quad screen (or triple screen) that screens for common chromosomal abnormalities. Low levels of MSAFP, often combined with abnormal levels of other markers like β-hCG, unconjugated estriol, and inhibin A, suggest an increased risk for this aneuploidy.
Choice C rationale
Phenylketonuria (PKU) is an inherited metabolic disorder where the body cannot properly metabolize the amino acid phenylalanine due to a deficiency of the enzyme phenylalanine hydroxylase. It is not directly associated with elevated MSAFP levels. PKU is screened for in newborns via a heel stick blood test, usually 24 to 48 hours after birth.
Choice D rationale
Hemophilia is an X-linked recessive bleeding disorder caused by a deficiency in specific clotting factors, typically factor VIII (Hemophilia A) or factor IX (Hemophilia B). This condition involves defective hemostasis and is not indicated by an elevated MSAFP. Hemophilia is often diagnosed through specific clotting factor assays.
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