A nurse is reinforcing teaching about perineal care to a client who is 2 hr postpartum and has an episiotomy and hemorrhoids. Which of the following statements by the client indicates an understanding of the teaching?
"I will place a heat pack to the area several times a day.
"I will apply witch hazel pads after urination."
"I will use the numbing spray prior to cleansing the area."
"I will remain in the sitz bath for 10 minutes."
The Correct Answer is B
A) Incorrect- Applying a heat pack to the area might increase inflammation and discomfort. Heat is generally not recommended for healing episiotomies and hemorrhoids.
B) Correct - "I will apply witch hazel pads after urination" is the correct statement. Witch hazel pads have a cooling and soothing effect that can provide relief from discomfort associated with episiotomies and hemorrhoids.
C) Incorrect- Using a numbing spray before cleansing might not be necessary and could interfere with proper cleansing. It's generally recommended to cleanse the area before applying any products.
D) Incorrect- Remaining in a sitz bath for 10 minutes is beneficial for perineal care, but it doesn't specifically address the use of witch hazel pads or understanding of the overall perineal care regimen. Furthermore, prolonged sitz baths, as can interfere with healing and increase the risk of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect- the fundal height corresponds with approximately 16 weeks. At around 16 weeks of gestation, the fundal height is usually located approximately at the midpoint between the symphysis pubis (pubic bone) and the belly button (umbilicus). This measurement corresponds to the anatomical level of the uterus at this stage.
B) Incorrect- the fundal height corresponds with approximately 20 weeks. By 20 weeks of gestation, the fundus has typically reached the level of the umbilicus. The fundal height measurement is around the same level as the belly button.
C) Correct- the fundal height corresponds with approximately 32 weeks. Around 32 weeks of gestation, the fundal height has increased significantly compared to earlier stages of pregnancy. The fundus of the uterus is located above the belly button, and the measurement is typically about 32 centimeters (or roughly 12.6 inches) above the symphysis pubis.
D) Incorrect- the fundal height corresponds with approximately 24 weeks. Around 24 weeks of gestation, the fundal height is usually about 1 to 2 fingerbreadths above the
umbilicus. This represents the ongoing upward growth of the uterus as the pregnancy progresses.
E) Incorrect- the fundal height corresponds with approximately 18 weeks. At around 18 weeks of pregnancy, the fundal height is typically located just above the pubic bone, below the belly button (umbilicus). The fundus of the uterus is still relatively low in the abdomen at this point. The fundal height measurement at 18 weeks is usually around the midpoint between the symphysis pubis (pubic bone) and the belly button.
Correct Answer is C
Explanation
A) Incorrect- Tachycardia (elevated heart rate) can be a common physiological response to pain or other factors and is not necessarily indicative of an adverse effect of epidural anesthesia.
B) Incorrect- Fever might be related to various factors, including infection, and is not directly indicative of an adverse effect of epidural anesthesia.
C) Correct - Tachypnea (rapid breathing) can be an adverse effect of epidural anesthesia.
It can indicate that the anesthesia has spread too high in the spinal column, potentially affecting the respiratory muscles and causing respiratory distress.
D) Incorrect- Hypertension might be a side effect of epidural anesthesia, but tachypnea is a more specific indication of an adverse effect in this context.
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