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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A rationale:

This is the correct choice. The American Academy of Pediatrics (AAP) recommends keeping children in a rear-facing car seat until they reach the age of 2 or until they reach the maximum weight and height allowed by the car seat's manufacturer. This is because rear- facing seats provide better support for a baby's head, neck, and spine during a crash, reducing the risk of injury.

Choice B rationale:

Placing the retainer clip over the upper part of the baby's abdomen is incorrect and potentially dangerous. The retainer clip should be positioned at armpit level to secure the harness straps properly.

Choice C rationale:

Placing the baby in the car seat at a 90-degree angle is not necessary. The car seat should be installed according to the manufacturer's instructions, and the angle will vary based on the specific car seat model.

Choice D rationale:

Placing the shoulder harness straps in the slots an inch above the baby's shoulders is incorrect. The straps should be positioned at or below the baby's shoulders for rear-facing car seats and at or above the shoulders for forward-facing seats.

A. Instruct the client to wash their hands prior to breastfeeding. B. Teach the client about proper latching-on techniques. C. Encourage the client to alternate breastfeeding with formula feeding. D. Instruct the client to avoid using a breast pump. E. Encourage the client to allow their nipples to air dry after feedings.

Correct Answer is ["A","B","E"]

Explanation

Choice A rationale:

Instructing the client to wash their hands before breastfeeding helps prevent the transmission of infection to the breast and the baby.

Choice B rationale:

Teaching the client about proper latching-on techniques ensures effective breastfeeding, reduces the risk of nipple damage, and promotes comfort for both the client and the baby.

Choice C rationale:

Encouraging the client to alternate breastfeeding with formula feeding is not recommended for a client with mastitis. Mastitis is an inflammation of the breast tissue often caused by bacterial infection, and continuing breastfeeding helps to clear the infection and maintain milk supply.

Choice D rationale:

Instructing the client to avoid using a breast pump is not necessary in this situation. Breastfeeding and pumping can continue to help drain the breast adequately, which is essential for resolving mastitis.

Choice E rationale:

Encouraging the client to allow their nipples to air dry after feedings helps promote healing and prevents further irritation to the nipples.

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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?

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