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 B
Explanation
Choice A rationale
A BP of 105/62 mm Hg is within the expected normal range for a postpartum adolescent client. A typical normotensive range is 90-140 mm Hg systolic and 60-90 mm Hg diastolic. Opioids like morphine can cause mild hypotension, but this reading doesn't indicate an immediate, life-threatening crisis.
Choice B rationale
A respiratory rate of 11/min is the priority because it signifies respiratory depression, a life-threatening, dose-related adverse effect of opioid analgesics like morphine. The normal respiratory rate for an adolescent is 12-20 breaths/min. Rates ≤ 12/min require immediate intervention, including potential administration of an opioid antagonist like naloxone.
Choice C rationale
Urinary retention is a common side effect of opioid administration due to increased bladder sphincter tone and reduced detrusor muscle contractility. While uncomfortable and potentially leading to urinary tract infection or bladder damage, it is less acute and life-threatening than respiratory depression.
Choice D rationale
Blurred vision can be an uncommon side effect of morphine, possibly due to miosis (pupil constriction) or minor changes in intraocular pressure. This finding requires further assessment but is a non-life-threatening adverse effect and does not pose the immediate threat of respiratory depression.
Correct Answer is C
Explanation
Choice A rationale
While bonding time is crucial for establishing parent-newborn attachment, it is not the immediate priority during the third stage of labor. The third stage is the period from the baby's birth until the placenta is delivered. The newborn's physiological stability, particularly temperature regulation and respiratory transition, takes precedence over private bonding immediately after birth.
Choice B rationale
Applying identification bands is a critical safety measure to prevent infant abduction or mix-up. However, it is not the absolute first action the nurse should take. Thermoregulation and initial stabilization, such as drying, are the immediate priorities to prevent cold stress and ensure the newborn's physiological adaptation before applying bands or allowing prolonged bonding.
Choice C rationale
Drying the newborn with clean towels is the first and most critical action to prevent heat loss through evaporation. Immediate drying and removing the wet linens are essential for thermoregulation and preventing cold stress, which can lead to increased oxygen consumption and metabolic acidosis. This action also provides tactile stimulation, which can help initiate or sustain respirations.
Choice D rationale
Checking the newborn's axillary temperature is an essential step for monitoring thermoregulation. However, it is an assessment action that follows the intervention of drying the baby. Immediate drying is the priority to prevent heat loss and stabilize the baby's temperature; the temperature check is then used to evaluate the effectiveness of the warming measures.
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