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.
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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Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Gestational age of 35-38 weeks.
This is because preterm babies are more likely to develop jaundice due to their immature liver and increased breakdown of red blood cells.Babies born between 35 and 38 weeks are considered late preterm and have a higher risk of jaundice than full-term babies.
Choice A is wrong because African American ethnicity is not a risk factor for jaundice.In fact, Asian, European, or native American ethnicity are more associated with jaundice.
Choice B is wrong because meconium-stained amniotic fluid is not a risk factor for jaundice.
Meconium is the first stool of the baby and it may indicate fetal distress, but it does not affect the bilirubin level.
Choice C is wrong because bottle feeding is not a risk factor for jaundice.In fact, breastfeeding is more associated with jaundice due to dehydration and poor caloric intake.
Correct Answer is D
Explanation
The correct answer is choice D. Wear a supportive bra.This will help suppress lactation and reduce the discomfort of engorgement.
The other choices are wrong because:
• Choice A. Manually express colostrum as necessary.This will stimulate milk production and prolong engorgement.
• Choice B. Apply hot compresses to the breasts.This will increase blood flow and swelling in the breasts and worsen engorgement.
• Choice C. Massage the breast tissue surrounding the areola.This will also stimulate milk production and prolong engorgement.
Normal ranges for breast engorgement are not applicable as it is a subjective experience that varies among women.However, some signs of engorgement include firm, tender, swollen breasts, flat or inverted nipples, and low-grade fever.Engorgement usually resolves within 24 to 36 hours after it begins.
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