A nurse is caring for a client who is 12 hours postpartum and has an episiotomy.
Which of the following actions should the nurse take?
Instruct the client to apply warm packs to the perineum every 8 hours.
Encourage the client to take a sitz bath twice per day.
Tell the client to apply antibiotic ointment to the perineal area four times per day.
Explain to the client how to dry her perineum by wiping with toilet tissue after each void.
The Correct Answer is B
Choice A rationale
Applying warm packs during the initial 24 hours postpartum is generally contraindicated for an episiotomy site. Heat promotes vasodilation, which could increase swelling and edema in the traumatized perineal tissues, exacerbating pain and potentially increasing blood loss. Cold therapy, such as ice packs, is the preferred intervention initially, as it causes vasoconstriction, reducing localized edema and numbing the area for pain relief.
Choice B rationale
Encouraging the client to take a sitz bath twice daily is an appropriate intervention for an episiotomy, typically after the first 24 hours postpartum when the initial swelling has subsided. The warm water promotes vasodilation, which improves circulation to the perineal area. This enhanced blood flow facilitates healing and offers soothing relief from pain and discomfort, aiding in tissue regeneration and cleanliness.
Choice C rationale
Applying antibiotic ointment to a routine episiotomy is generally not recommended unless there are signs of infection or a specific prescription is provided. The wound is clean, and the risk of introducing pathogens outweighs the routine benefit. Proper hygiene with cleansing after elimination, using a peri-bottle with warm water, and changing pads frequently is the standard of care to prevent infection and promote natural healing.
Choice D rationale
Instructing the client to wipe the perineum with toilet tissue after voiding is incorrect and can be detrimental to episiotomy healing. Wiping, particularly from back to front, can introduce fecal bacteria into the episiotomy site or vagina, increasing the risk of infection. The client should be instructed to use a peri-bottle filled with warm water to gently rinse the area after elimination and then pat dry with a clean cloth or tissue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While heroin use, an opioid, is associated with various adverse pregnancy outcomes, its direct causation of placenta previa is not a primary, established link. Placenta previa, the implantation of the placenta over the cervical os, is more commonly linked to risk factors such as previous Cesarean birth, advanced maternal age, and multiparity, rather than a direct pharmacological effect of heroin on uterine implantation sites.
Choice B rationale
Increased amniotic fluid (polyhydramnios) is often associated with conditions like maternal diabetes, fetal gastrointestinal or central nervous system anomalies, or twin to twin transfusion syndrome. Heroin use is primarily associated with decreased amniotic fluid (oligohydramnios) and Intrauterine Growth Restriction (IUGR), a consequence of vasoconstriction and compromised uteroplacental perfusion.
Choice C rationale
Opioid use, including heroin, is a significant risk factor for preterm labor (PTL). The vasoconstrictive effects of heroin on the uteroplacental circulation can lead to ischemia and placental abruption, both of which are strong triggers for uterine irritability and the initiation of PTL (delivery before 37 weeks gestation), posing a high risk for the fetus.
Choice D rationale
Heroin use is a teratogen and is associated with multiple adverse effects, including IUGR and Neonatal Abstinence Syndrome (NAS). However, heroin itself is not typically classified as a primary cause of chromosomal abnormalities, which are structural or numerical errors in the genetic material, usually arising from meiotic nondisjunction or inherited genetic defects, rather than an opioid's pharmacologic action.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}
Explanation
- Cover the newborn's eyes with an eye shield ✅ This is essential to prevent retinal damage from the phototherapy light.
- Reposition the newborn every 2 to 3 hr ✅ Repositioning ensures even exposure to light and prevents pressure injuries.
- Apply lotion to the newborn's skin regularly ❌ Lotion is contraindicated as it may interfere with light absorption and increase the risk of burns.
- Ensure the newborn wears a hat during phototherapy ❌ A hat reduces the surface area exposed to light, decreasing phototherapy effectiveness.
- Move the lights closer to the newborn to increase temperature ❌ Phototherapy lights should be positioned at a safe distance to avoid overheating or burns. Temperature should be monitored, not manipulated this way.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.