A patient had an episiotomy during her delivery. Which nursing action should be included in her plan of care for the first 12 hours?

Have her do Kegel exercises once an hour.

Apply ice to her perineal area.

Keep her hips slightly elevated.

Observe her perineal area for signs of infection.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B. Apply ice to her perineal area. This is because ice can help reduce swelling and pain in the episiotomy wound, which is a cut made in the tissue between the vagina and anus during childbirth. Ice should be applied for the first 24 to 48 hours after delivery.

Choice A is wrong because Kegel exercises, which involve contracting and relaxing the pelvic floor muscles, are not recommended for the first 12 hours after an episiotomy. They can increase blood flow and inflammation in the area, and may interfere with healing.

Choice C is wrong because keeping her hips slightly elevated can cause pressure on the episiotomy wound and increase discomfort. It can also affect blood circulation and drainage in the area.

Choice D is wrong because observing her perineal area for signs of infection is not a nursing action that should be included in her plan of care for the first 12 hours. Infection is rare in episiotomy wounds, and signs of infection usually appear after 24 hours or later. However, the nurse should teach the patient how to keep the area clean and dry, and when to report any signs of infection, such as fever, pus, or foul-smelling discharge.

Normal ranges for episiotomy healing are:

• Stitches dissolve within 2 to 4 weeks

• Pain and swelling subside within a few days to a week

• Wound heals completely within 4 to 6 weeks

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Correct Answer is C

Explanation

This is because the patient is experiencing supine hypotension syndrome, which occurs when the weight of the gravid uterus compresses the inferior vena cava and reduces venous return and cardiac output. Turning the patient onto her side will relieve the pressure and improve blood flow.

Choice A is wrong because taking the patient’s blood pressure will not address the cause of her symptoms and may delay appropriate intervention.

Choice B is wrong because breathing into her cupped hands will not improve her circulation and may increase her carbon dioxide levels.

Choice D is wrong because elevating the patient’s legs will not relieve the compression of the inferior vena cava and may worsen her condition.Normal blood pressure for a pregnant woman is 110/70 to 120/80 mmHg.Normal heart rate for a pregnant woman is 60 to 90 beats per minute.Normal respiratory rate for a pregnant woman is 16 to 24 breaths per minute.

A. Forceps-assisted second stage of labor. B. Precipitous delivery. C. Prolonged first phase of labor. D. Cesarean delivery.

Correct Answer is D

Explanation

The correct answer is choice D. Cesarean delivery.A pregnant patient with genital herpes is at higher risk of transmitting the infection to the baby during vaginal delivery, especially if there is an active outbreak near the time of birth.This can cause serious complications for the baby, such as brain damage, eye problems, or even death.Therefore, a cesarean delivery is recommended to avoid contact between the baby and the genital lesions.

Choice A is wrong because forceps-assisted second stage of labor is not a complication of genital herpes.

It is a method of assisted delivery that may be used for various reasons, such as fetal distress, maternal exhaustion, or abnormal presentation.

Choice B is wrong because precipitous delivery, which means a very fast labor and delivery, is not a complication of genital herpes.

It may be caused by factors such as multiparity, strong contractions, or previous rapid deliveries.

Choice C is wrong because prolonged first phase of labor, which means a slow dilation of the cervix, is not a complication of genital herpes.

It may be caused by factors such as ineffective contractions, large fetal size, or malposition.

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A patient had an episiotomy during her delivery. Which nursing action should be included in her plan of care for the first 12 hours?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

When a pregnant patient has genital herpes, for which complication is the patient at higher risk than the general population?

Correct Answer is D

Explanation

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