A nurse is caring for a postpartum client who has an episiotomy wound infection.

Which of the following should the nurse do? (Select all that apply.) A) Administer antibiotics as prescribed.

Monitor wound healing.

Teach wound care.

Culture wound if indicated.

Apply heat to wound.

Answer and Explanation

Correct Answer : A,B,C,D

The correct answer is choice A, B, C and D. Antibiotics, wound monitoring, wound care and wound culture are all appropriate interventions for a postpartum client who has an episiotomy wound infection. According to Mayo Clinic, an episiotomy wound infection can cause pain, fever, pus and wound breakdown. According to SpringerLink, an episiotomy wound infection is usually caused by a polymicrobial infection of Gram-negative and Gram-positive bacteria.

Therefore, administering antibiotics as prescribed can help treat the infection and prevent complications.

Monitoring wound healing can help detect any signs of worsening infection or dehiscence.

Teaching wound care can help the client prevent further contamination and promote healing.

Culturing the wound if indicated can help identify the causative organisms and guide antibiotic therapy.

Choice E is wrong because applying heat to the wound can increase inflammation and pain. According to NCBI, there is no evidence that heat therapy is beneficial for episiotomy wounds.

Instead, cold therapy may be more effective in reducing swelling and discomfort.

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Correct Answer is E

Explanation

The correct answer is choice E) Temperature greater than 38°C for more than 48 hours.This is because a fever higher than 38°C that lasts for more than two days can indicate a postpartum infection, which is a potentially serious complication that requires immediate medical attention.A postpartum infection can affect various parts of the body, such as the uterus, the breast, or the urinary tract.

Choice A) Lochia with clots is wrong because lochia is the normal vaginal discharge that occurs after childbirth and may contain some blood clots.However, if the lochia is foul-smelling, excessive, or bright red, it may be a sign of infection.

Choice B) Fundus firmness is wrong because a firm fundus (the top of the uterus) indicates that the uterus is contracting well and preventing excessive bleeding.A soft or boggy fundus can be a sign of infection or hemorrhage.

Choice C) Abdominal distension is wrong because some abdominal swelling is normal after delivery and may take several weeks to subside.However, if the abdomen is very tender, painful, or hard, it may be a sign of infection or other complications.

Choice D) Breast tenderness is wrong because some

A. Use a sitz bath three times per day and after each bowel movement B. Wipe from back to front after voiding or having a bowel movement C. Apply ice packs to the perineum for the first 24 hours D. Perform Kegel exercises several times per day E. Report any increase in redness, swelling, or discharge from the episiotomy site.

Correct Answer is ["A","C","D","E"]

Explanation

The correct answer is choice A, C, D and E. These are the instructions that the nurse should include in the teaching for a client who had a vaginal delivery with a midline episiotomy.

• Choice A is correct because using a sitz bath three times per day and after each bowel movement can help reduce pain, swelling and infection of the perineum.

• Choice C is correct because applying ice packs to the perineum for the first 24 hours can help reduce inflammation and bleeding.

• Choice D is correct because performing Kegel exercises several times per day can help strengthen the pelvic floor muscles and improve urinary continence.

• Choice E is correct because reporting any increase in redness, swelling or discharge from the episiotomy site can help detect signs of infection or wound breakdown.

• Choice B is wrong because wiping from back to front after voiding or having a bowel movement can increase the risk of infection by introducing bacteria from the anal area to the vaginal area.The correct way to wipe is from front to back.

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A nurse is caring for a postpartum client who has an episiotomy wound infection. Which of the following should the nurse do? (Select all that apply.) A) Administer antibiotics as prescribed.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a postpartum client for signs of infection. Which of the following should the nurse report immediately? A) Lochia with clots.

Correct Answer is E

Explanation

A nurse is providing discharge teaching to a client who had a vaginal delivery with a midline episiotomy. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["A","C","D","E"]

Explanation

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A nurse is caring for a postpartum client who has an episiotomy wound infection.

Which of the following should the nurse do? (Select all that apply.) A) Administer antibiotics as prescribed.