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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. When the neonate responds to the mother by some signal, attachment behavior is stimulated in the mother.This is based on therooting reflex, which helps the baby find the breast or bottle to start feeding and also promotes bonding between the mother and the baby.
Choice A is wrong because acrocyanosis is a normal condition in newborns that causes bluish discoloration of the hands and feet due to poor circulation.It is not related to muscle tone or reflexes.
Choice B is wrong because myelinization of nerves is a process that occurs gradually during development and is not influenced by tactile stimulation.Myelin is a fatty substance that covers nerve fibers and helps them transmit signals faster and more efficiently.
Choice D is wrong because reflexes are involuntary movements or actions that do not depend on conscious thought or learning.They are not directly related to growth patterns, although they may indicate the health and development of the brain and nervous system.
Correct Answer is A
Explanation
The correct answer is choice A. A breastfed baby is likely to gain weight more rapidly in the first month of life.This statement is wrong because breastfed babies generally gain weight faster than formula-fed babies for the first 3 months of life.They also double their birth weight by 3-4 months and triple it by one year.
Therefore, a breastfed baby’s weight gain in the first month of life is not unusual or concerning.
Choice B is correct because breastfeeding is not a reliable method of birth control.A woman can still ovulate and become pregnant while breastfeeding, especially if she feeds her baby less frequently or supplements with formula or solids.
Choice C is correct because breastfeeding has been shown to reduce the risk of allergies in babies.Breast milk contains antibodies and other immune factors that protect the baby from infections and allergic reactions.
Choice D is correct because breastfeeding mothers need to drink enough fluids to stay hydrated and produce enough milk.The recommended fluid intake for breastfeeding mothers is about 13 cups (3 liters) per day.
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