A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take?
Apply an ice pack to the affected area.
Offer a warm sitz bath.
Provide a squeeze bottle of antiseptic solution.
Place a hot pack to the perineum.
The Correct Answer is A
The correct answer is A. Apply an ice pack to the affected area. Ice packs are recommended during the first 24 hours after birth to decrease swelling and help with pain.
Choice A reason: Applying an ice pack to the episiotomy site helps reduce swelling and provides pain relief. This is the standard care within the first 24 hours postpartum.
Choice B reason: A warm sitz bath is generally recommended after the first 24 hours following birth. It is not the best immediate action for unrelieved pain shortly after delivery.
Choice C reason: While maintaining cleanliness with a squeeze bottle of antiseptic solution is important for preventing infection, it does not provide the immediate pain relief needed for unrelieved episiotomy pain.
Choice D reason: Heat application, such as placing a hot pack, is not advised within the first 24 hours postpartum because it can increase the risk of swelling and bleeding.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Administering oxytocin to the client via intravenous infusion is not appropriate when the nurse notes an umbilical cord protruding through the cervix. The priority is to relieve pressure on the cord to prevent fetal compromise, and administering oxytocin could worsen the situation.
Choice B rationale:
Applying oxygen at 2 L/min via nasal cannula is not the priority when an umbilical cord prolapse is detected. The focus should be on relieving pressure on the cord and changing the client's position to alleviate the compression.
Choice C rationale:
Preparing for insertion of an intrauterine pressure catheter is not appropriate when there is an umbilical cord prolapse. The immediate concern is the potential compromise of fetal blood flow, and addressing the cord prolapse takes precedence over any other interventions.
Choice D rationale:
Assisting the client into the knee-chest position is the correct action when an umbilical cord prolapse is observed during a vaginal exam. This position helps to alleviate pressure on the cord by moving the presenting part of the fetus off the cord and can prevent further fetal distress until more definitive interventions can be performed.
Correct Answer is A
Explanation
Choice A rationale:
Naegele's Rule is used to estimate the expected delivery date (EDD) by adding 7 days and 9 months to the first day of the last menstrual period (LMP) In this case, May 4th, 2018, is the first day of the LMP. Adding 7 days brings us to May 11th, and then adding 9 months brings us to February 11th, 2019, which is the estimated delivery date.
Choice B rationale:
This option is incorrect because it adds 9 months to the LMP without accounting for the additional 7 days, resulting in an inaccurate EDD.
Choice C rationale:
This option is incorrect because it only adds 9 months to the LMP without considering the 7 days, leading to an inaccurate EDD.
Choice D rationale:
This option is incorrect because it adds 9 months to the LMP without considering the 7 days, resulting in an inaccurate EDD.
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