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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
This statement is incorrect. A nonstress test does not involve receiving medication through an
IV. It is a simple and non-invasive test that monitors the baby's heart rate in response to its movements.
Choice B rationale:
This is the correct choice. A nonstress test typically takes about 30 minutes to complete. During the test, the client will have a fetal heart rate monitor placed on her abdomen to measure the baby's heart rate while it is moving.
Choice C rationale:
This statement is incorrect. There is no requirement for the client to fast or restrict food and drink before a nonstress test. The client can eat and drink as usual before the procedure.
Choice D rationale:
This statement is incorrect. A nonstress test is not used to determine if the baby's lungs are mature. Instead, it assesses the baby's heart rate patterns in response to its own movements, which helps evaluate the baby's overall well-being in the third trimester of pregnancy.
Correct Answer is D
Explanation
Choice A reason:
"Retract the foreskin until you feel resistance." This advice is not recommended for newborns with an uncircumcised penis. The foreskin of most male babies doesn't yet pull back (retract) fully at birth, and forcing it back can cause pain, bleeding, and possible damage.
Choice B reason:
"Use a cotton swab to clean under the foreskin." This is not advisable for a newborn's uncircumcised penis. The foreskin is usually still attached to the glans and does not require any special cleaning inside. Using a cotton swab could potentially cause harm by forcing the foreskin back.
Choice C reason:
"Apply petroleum jelly to the foreskin." This instruction is more applicable to a circumcised penis during the healing process to prevent the penis from sticking to the diaper. For an uncircumcised penis, there's no need to apply petroleum jelly as part of regular care.
Choice D reason:
"Wash the penis once per day with soap and water." This is the correct care for an uncircumcised penis. Parents should gently wash the genital area with mild soap and water during bath time without retracting the foreskin.
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