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.
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.
Encourage the client to take a sitz bath twice per day.
The Correct Answer is D
Choice A rationale
Applying warm packs to the perineum is generally discouraged in the immediate postpartum period, especially within the first 24 hours, due to the risk of increasing swelling and discomfort. Cold applications are typically preferred initially to promote vasoconstriction, which helps to reduce edema and numb the area, offering greater pain relief.
Choice B rationale
Routine application of antibiotic ointment to an episiotomy is not standard practice unless there are signs of infection. Episiotomies are clean-contaminated wounds, and prophylactic antibiotic use is generally avoided to prevent the development of antibiotic resistance and disruption of the normal perineal flora. Aseptic wound care is prioritized.
Choice C rationale
Wiping the perineum with toilet tissue after voiding can introduce bacteria from the anal area into the healing episiotomy site, increasing the risk of infection. Perineal care should involve rinsing the area with warm water (e.g., using a peri-bottle) and patting it dry from front to back to minimize bacterial contamination and promote healing.
Choice D rationale
Encouraging the client to take a sitz bath twice per day is beneficial for episiotomy care. The warm water promotes vasodilation, increasing blood flow to the perineal area, which aids in healing and reduces discomfort. It also helps to keep the area clean and can soothe irritated tissues, facilitating recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Nalbuphine hydrochloride is an opioid agonist-antagonist analgesic that primarily acts on kappa opioid receptors, producing analgesia, and partially on mu opioid receptors, which can lead to adverse effects like sedation. Sedation is a common central nervous system depressant effect of opioid medications due to their action on specific brainstem and cortical regions, altering neurotransmission and decreasing overall neuronal excitability. The degree of sedation can vary depending on the dosage and individual patient sensitivity.
Choice B rationale
Fever is an elevated body temperature and is not a direct adverse effect typically associated with nalbuphine hydrochloride. Fever is more commonly indicative of an infectious process, inflammatory response, or certain drug reactions (e.g., drug fever), but it is not a direct pharmacological action or common side effect of opioid analgesics like nalbuphine. Opioids generally do not affect thermoregulation in a way that causes a fever.
Choice C rationale
Diarrhea is characterized by loose, watery stools and is not a common adverse effect of nalbuphine hydrochloride. Opioids, in general, are more known for causing constipation due to their effects on decreasing gastrointestinal motility and increasing fluid absorption in the intestines, by acting on opioid receptors in the enteric nervous system. Therefore, diarrhea would be an atypical and unexpected response to nalbuphine.
Choice D rationale
Diuresis refers to increased urine production and is not a typical adverse effect of nalbuphine hydrochloride. Opioids can sometimes affect antidiuretic hormone (ADH) secretion, potentially leading to fluid retention or oliguria rather than diuresis. Diuresis is usually associated with diuretic medications or certain physiological conditions that promote increased urine output, which is contrary to the expected effects of opioids on renal function.
Correct Answer is A
Explanation
Choice A rationale
Iron is essential for the production of hemoglobin, which is the oxygen-carrying protein in red blood cells. During pregnancy, maternal blood volume increases significantly, requiring a greater production of red blood cells to meet the increased oxygen demands of both the mother and the developing fetus. The recommended daily intake for pregnant women is 27 mg.
Choice B rationale
Calcium is crucial for fetal bone and tooth development, as well as for maintaining maternal bone health. While important, it does not directly contribute to the increase in maternal blood volume. The recommended daily intake is 1000 mg for pregnant women.
Choice C rationale
Vitamin E is an antioxidant that plays a role in protecting cells from damage. While it has various physiological functions, it is not directly involved in the process of increasing maternal blood volume.
Choice D rationale
Vitamin D is important for calcium absorption and bone health in both the mother and the fetus. It also plays a role in immune function. However, it does not directly contribute to the increase in maternal blood volume. The recommended daily intake is 600 IU for pregnant women.
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