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 D

Explanation

he correct answer is choice D. Keep the infant well hydrated.This is because phototherapy can cause dehydration due to increased insensible water loss from the skin.Hydration helps the infant excrete bilirubin in urine and stool.

Choice A is wrong because elevating the head of the infant’s crib does not affect bilirubin levels or phototherapy effectiveness.

Choice B is wrong because applying a water-soluble ointment to the infant’s eyes can interfere with eye protection and cause eye irritation.The infant’s eyes should be covered with opaque patches or goggles during phototherapy to prevent eye damage.

Choice C is wrong because dressing the infant in a long-sleeved shirt reduces the amount of skin exposed to light and decreases the efficacy of phototherapy.The infant should be undressed except for a diaper and eye protection during phototherapy.

Normal ranges for bilirubin levels vary depending on the age of the infant, the type of jaundice, and the method of measurement.Generally, bilirubin levels above 25 mg/dL are considered dangerous and require urgent treatment.

A. Sole creases that cover only the anterior one-third of the foot. B. Abundance of vernix caseosa in the skin creases. C. Dryness and flaking of the skin on the hands and feet. D. Large amount of fine, downy hair on the back and shoulders.

Correct Answer is C

Explanation

The correct answer is choice C. Dryness and flaking of the skin on the hands and feet.This is because a newborn with a gestational age of 42 weeks is considered post-mature and has lost the protective vernix caseosa that covers the skin of most newborns.The skin of a post-mature newborn is also more exposed to the amniotic fluid, which can cause it to peel and crack.

Choice A is wrong because sole creases that cover only the anterior one-third of the foot are characteristic of a preterm newborn, not a post-mature one.

Choice B is wrong because vernix caseosa is abundant in preterm newborns and decreases as gestational age increases.A post-mature newborn would have little or no vernix caseosa on the skin.

Choice D is wrong because a large amount of fine, downy hair (lanugo) on the back and shoulders is also typical of a preterm newborn, not a post-mature one.Lanugo usually disappears by 36 weeks of gestation.A post-mature newborn would have little or no lanugo on the body.

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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 newborn develops hyperbilirubinemia when 24 hours old and is prescribed phototherapy. Which measure is an important part of this newborn’s care plan?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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