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

The correct answer is choice C.Choice C is wrong because having more than three full-term pregnancies does not affect the suitability of using a copper IUD as a birth control method.Copper IUDs are long-term, reversible contraceptives that can be used by premenopausal women of all ages, including those who have never been pregnant or who have had multiple pregnancies.

Choice A is correct because a copper IUD can be inserted anytime during a normal menstrual cycle, or up to eight weeks after childbirth.

Choice B is correct because a copper IUD may cause heavier and longer periods, as well as more cramping.

Choice D is correct because a copper IUD works by creating an inflammatory response in the uterus that prevents sperm from reaching the egg and fertilizing it, and also prevents a fertilized egg from implanting in the uterine wall.

A. Hemorrhage. B. Urinary retention. C. Impending convulsion. D. Thrombophlebitis.

Correct Answer is C

Explanation

This is because pregnancy-induced hypertension (PIH) can cause eclampsia, a condition characterized by seizures and coma.Eclampsia can occur during pregnancy, labor, or postpartum.

A nurse should monitor the client for signs of increased blood pressure, headache, blurred vision, epigastric pain, and hyperreflexia, which may indicate an impending convulsion.

Choice A is wrong because hemorrhage is not a common complication of PIH.

Hemorrhage may occur due to other causes such as uterine atony, lacerations, or retained placenta.

Choice B is wrong because urinary retention is not a common complication of PIH.

Urinary retention may occur due to other causes such as anesthesia, trauma, or infection.

Choice D is wrong because thrombophlebitis is not a common complication of PIH.

Thrombophlebitis is a condition where a blood clot forms in a vein and causes inflammation.

It may occur due to other risk factors such as immobility, dehydration, or injury.

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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

A nurse is providing information to a patient regarding contraception methods. Which statement by the patient indicates a need for further teaching regarding use of copper intrauterine device (IUD)?

Correct Answer is C

Explanation

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Correct Answer is C

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