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. “What drugs have you used during your pregnancy?”.
This question is open-ended and nonjudgmental, which encourages the patient to disclose more information about her drug use.
The nurse can then assess the type, frequency, and amount of drugs used and plan appropriate interventions.
Choice A is wrong because it is a closed-ended question that can be answered with a yes or no, and it implies criticism of the patient’s behavior, which may make her defensive and less willing to cooperate.
Choice B is wrong because it is also a closed-ended question that can be answered with a yes or no, and it may frighten or anger the patient, who may not be aware of the legal implications of her drug use.
Choice D is wrong because it is too vague and may not cover all the possible drugs that the patient may have used, such as prescription medications, alcohol, or tobacco.
It also labels the patient as a drug user, which may offend her or make her feel ashamed.
Correct Answer is B
Explanation
The correct answer is choice B. The administration route of terbutaline will be changed from intravenous to oral.
This is because terbutaline is a medication that can be used to suppress preterm labor by relaxing the uterine smooth muscle.It can be given subcutaneously or intravenously for acute episodes of preterm labor, but it is not recommended for long-term use due to the risk of serious maternal and fetal adverse effects.Therefore, if the client’s condition stabilizes, the administration route of terbutaline will be changed from intravenous to oral, which has a lower bioavailability and less systemic effects.
Choice A is wrong because terbutaline is not usually self-administered parenterally by the client at home.It requires a trained health professional to give it as a shot under the skin or through a vein.
Choice C is wrong because the client does not need to remain in a private room without visitors until she has been without contractions for 48 hours.
This is an unnecessary restriction that may increase the client’s stress and anxiety.
The client should be encouraged to have social support and emotional comfort during this time.
Choice D is wrong because the client should not ambulate in the hallway after 12 hours without contractions.
This may stimulate uterine activity and cause a recurrence of preterm labor.
The client should follow the provider’s instructions on bed rest and activity limitations.
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