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 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.
Correct Answer is D
Explanation
The correct answer is choice D. “Have you noticed any tenderness in your breasts?”
Breast tenderness is one of the early signs of pregnancy that may occur as early as one to two weeks after conception.It is caused by hormonal changes that prepare the breasts for lactation.
Choice A is wrong because shortness of breath is not a sign of early pregnancy.It may occur later in pregnancy due to the growing uterus pressing on the diaphragm.
Choice B is wrong because episodes of loss of consciousness are not a sign of early pregnancy.They may indicate a serious condition such as anemia, dehydration, or hypoglycemia that requires medical attention.
Choice C is wrong because spotting is not a sign of early pregnancy.
It may be a sign of implantation bleeding, which occurs when the fertilized egg attaches to the lining of the uterus.However, implantation bleeding is usually much lighter and shorter than a normal period.
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