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 ["C","D"]
Explanation
Choice A rationale
. Decreased urination, or oliguria, is typically associated with fluid volume deficit or impaired renal perfusion, not directly with uncomplicated hyperglycemia. In fact, hyperglycemia causes an osmotic diuresis because the excess glucose filtered by the glomeruli exceeds the renal tubules' reabsorption capacity. This results in the excretion of glucose, which draws water with it, leading to polyuria (increased urination), the opposite of the expected manifestation. Normal blood glucose is 70 to 100 mg/dL.
Choice B rationale
. Shallow respirations are not a characteristic sign of hyperglycemia in a client who is pregnant, unless the condition has progressed to severe diabetic ketoacidosis (DKA). DKA causes a metabolic acidosis, which triggers Kussmaul respirations—deep and labored breathing—as a compensatory mechanism to increase CO_2 elimination and raise the blood pH. Shallow breathing would decrease ventilation.
Choice C rationale
. Increased hunger, or polyphagia, is a classic manifestation of hyperglycemia due to the body's inability to utilize glucose effectively as an energy source, despite high blood glucose levels. The cells signal a state of starvation because glucose cannot enter the cells without sufficient insulin, prompting the release of neuropeptides that stimulate appetite and increased caloric intake.
Choice D rationale
. Increased thirst, or polydipsia, is a direct physiological response to the osmotic diuresis caused by hyperglycemia. The high concentration of glucose in the blood increases the plasma osmolarity, which pulls water from the intracellular space into the vascular space, causing cellular dehydration. This triggers the osmoreceptors in the hypothalamus, stimulating the sensation of thirst to encourage fluid intake.
Correct Answer is C
Explanation
Choice A rationale
Elevated maternal serum alpha-fetoprotein (MSAFP) levels are more often associated with intrauterine growth restriction (IUGR) due to placental compromise, which can lead to increased leakage of AFP into the maternal circulation. AFP is a glycoprotein produced by the fetal liver and yolk sac. Normal MSAFP levels vary by gestational week, but generally, a level ≥ 2.5 Multiples of the Median (MoM) is considered elevated.
Choice B rationale
Multiple gestation, such as twins or triplets, typically results in an elevated MSAFP because there are multiple fetuses producing AFP, leading to a higher total concentration in the maternal serum. This physiological increase requires adjustment of the median value used for interpretation to prevent false-positive results for neural tube defects.
Choice C rationale
Down syndrome (Trisomy 21) is associated with low MSAFP levels, often ≤ 0.75 MoM, along with decreased unconjugated estriol and increased human chorionic gonadotropin (hCG) and inhibin A in the quad screen. This specific pattern is due to complex, poorly understood pathophysiology related to the aneuploidy's effect on fetal protein synthesis and maternal-fetal exchange.
Choice D rationale
Neural tube defects (NTDs), such as spina bifida and anencephaly, are associated with markedly elevated MSAFP levels, usually ≥ 2.5 MoM. This is caused by the exposed fetal meninges or neural tissue leaking a large amount of AFP directly into the amniotic fluid, which then diffuses into the maternal circulation.
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