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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?

A.

Instruct the client to apply warm packs to the perineum every 8 hours.

B.

Encourage the client to take a sitz bath twice per day.

C.

Tell the client to apply antibiotic ointment to the perineal area four times per day.

D.

Explain to the client how to dry her perineum by wiping with toilet tissue after each void.

Answer and Explanation

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.


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Related Questions

Correct Answer is ["0.25"]

Explanation

Step 1 is to determine the volume needed using the formula: Volume = (Dose prescribed÷Concentration available). 0.5 mg÷ (1 mg / 0.5 mL).

Step 2 is to perform the division:. 0.5 × 0.5 mL.

Step 3 is to calculate the final volume:. 0.25 mL. The nurse should administer 0.25 mL.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Heel warming increases capillary blood flow, improving sample accuracy and reducing hemolysis risk. Capillary glucose testing requires adequate perfusion for reliable results. Breastfeeding provides immediate glucose substrate to correct mild hypoglycemia. Normal neonatal blood glucose is >40–45 mg/dL; this newborn’s initial level of 35 mg/dL is below threshold, but responsive to feeding. Breast milk contains lactose, metabolized to glucose and galactose, supporting cerebral energy demands.

Rationale for incorrect Response 1 options: Administer glucose gel is appropriate only if feeding fails or glucose remains <25 mg/dL in asymptomatic or <40 mg/dL in symptomatic neonates. This newborn improved with feeding. Start IV fluids is reserved for persistent hypoglycemia or symptomatic neonates unresponsive to oral intake. The newborn stabilized post-breastfeeding. Phototherapy treats hyperbilirubinemia, not hypoglycemia. No bilirubin levels or jaundice signs were reported.

Rationale for incorrect Response 2 options: Supplement with formula is secondary to breastfeeding unless maternal milk is unavailable or ineffective. Breastfeeding was successful post-latch correction. Administer insulin is contraindicated; insulin lowers glucose and is used only in hyperglycemia. Monitor for jaundice is unrelated to hypoglycemia management unless bilirubin levels are elevated. No clinical jaundice was noted.

Take-home points:

  • Neonatal hypoglycemia is defined as glucose <40–45 mg/dL; early feeding is first-line intervention.
  • Macrosomic infants (birth weight >4,000 g) are at risk due to hyperinsulinemia post-placental glucose withdrawal.
  • Differentiate hypoglycemia from sepsis, hypothermia, and metabolic disorders—all may present with jitteriness and hypotonia.
  • Capillary sampling requires heel warming to ensure perfusion and accurate glucose measurement.

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