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A nurse is caring for a client who is postpartum and has an episiotomy.
Which of the following actions should the nurse take?

A.

Instruct the client to apply anesthetic spray to the site three to four times a day.

B.

Encourage the client to change perineal pads at least three times a day.

C.

Assist the client to fill the squeeze bottle with cold water to perform perineal care.

D.

Alternate warm and ice packs to the site every 2 hours for the first 24 hours postpartum.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Instructing the client to apply anesthetic spray to the site three to four times a day is incorrect. While anesthetic sprays can help with pain relief, it's more important to manage swelling and discomfort with a combination of methods, including ice packs and perineal care.

Choice B rationale

Encouraging the client to change perineal pads at least three times a day is insufficient. Pads should be changed more frequently to maintain hygiene and prevent infection.

Choice C rationale

Assisting the client to fill the squeeze bottle with cold water to perform perineal care is incorrect. While perineal care is important, cold water is not typically recommended as it may not provide comfort and might even cause discomfort.

Choice D rationale

Alternating warm and ice packs to the site every 2 hours for the first 24 hours postpartum is correct. This method helps manage pain and swelling effectively, promoting healing and comfort for the client.


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Related Questions

Correct Answer is D

Explanation

Choice A rationale

Bumper pads can pose a suffocation risk to the newborn. The American Academy of Pediatrics advises against their use to promote a safe sleep environment.

Choice B rationale

Foam-wedge cushions are not recommended as they can increase the risk of suffocation and Sudden Infant Death Syndrome (SIDS) by obstructing airflow.

Choice C rationale

Plastic covers can pose a suffocation hazard. Instead, using a fitted sheet is safer and reduces the risk of suffocation.

Choice D rationale

A well-fitting mattress reduces gaps between the mattress and crib sides, preventing entrapment, which helps reduce the risk of suffocation and injury.

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

Explanation

The nurse should prepare to reinforce teaching with the client about a diabetic diet with a prescription of insulin therapy.

So, correct options are:

  1. A. diabetic diet
  2. A. insulin therapy
  3. Diabetic diet:
    1. The client has a history of gestational diabetes mellitus (GDM) during her previous pregnancy and is currently experiencing elevated blood glucose levels, as indicated by the oral glucose tolerance test and fasting glucose levels.
    2. A diabetic diet is essential to help manage blood glucose levels and prevent complications for both the mother and the baby.
  4. Insulin therapy:
    1. The client is already adhering to a diabetic diet and is taking insulin as prescribed, indicating that insulin therapy is part of her current management plan.
    2. Her glucose levels are still elevated despite dietary management, which means insulin therapy is necessary to maintain optimal glucose levels and reduce the risk of complications associated with GDM.

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