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 B

Explanation

Choice A rationale:

Hyporeactivity, or reduced responsiveness to stimuli, is not typically associated with neonatal abstinence syndrome (NAS) NAS is characterized by increased irritability and not reduced activity.

Choice B rationale:

An excessive high-pitched cry is a common manifestation of neonatal abstinence syndrome. Infants exposed to substances like methadone during pregnancy may experience heightened sensitivity and exhibit a high-pitched cry as a sign of withdrawal.

Choice C rationale:

Acrocyanosis, a bluish discoloration of the hands and feet, is not a specific indicator of neonatal abstinence syndrome. It is a common finding in newborns and often resolves on its own.

Choice D rationale:

A respiratory rate of 50/min is within the normal range for a newborn. It is not an indication of neonatal abstinence syndrome.

A. Restrict protein intake to less than 40 g/day. B. Initiate seizure precautions for the client. C. Initiate an infusion of 0.9% sodium chloride at 150 ml/hr. D. Encourage the client to ambulate twice per day.

Correct Answer is B

Explanation

Choice A rationale:

Restricting protein intake to less than 40 g/day is not appropriate for a client with preeclampsia with severe features. While protein restriction might be advised in some cases of preeclampsia, it is not a priority in severe cases where the focus is on managing potential complications.

Choice B rationale:

Initiating seizure precautions is essential in managing a client with preeclampsia with severe features. Preeclampsia can lead to eclampsia, a condition characterized by seizures. Seizure precautions involve implementing measures to prevent injury during a seizure, such as padding the side rails of the bed, ensuring a clear environment, and having emergency equipment readily available.

Choice C rationale:

Initiating an infusion of 0.9% sodium chloride at 150 ml/hr is not directly related to managing preeclampsia with severe features. Although intravenous fluids may be necessary in some cases, the priority in this situation is to prevent and manage potential seizures.

Choice D rationale:

Encouraging the client to ambulate twice per day is not appropriate for a client with preeclampsia with severe features. Bed rest is often recommended in severe cases to reduce stress on the cardiovascular system and decrease the risk of complications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn who is 48 hr old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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