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 B

Explanation

The correct answer is choice B. The client should avoid sexual intercourse.Sexual intercourse may stimulate uterine contractions and increase the risk of preterm labor.The client should also avoid activities that may cause dehydration, infection, or stress.

Choice A is wrong because documenting urine output hourly is not necessary for a client with preterm labor who is discharged home.Urine output may be affected by hydration status, kidney function, or medication use, but it is not a reliable indicator of preterm labor.

Choice C is wrong because maintaining a darkened, quiet environment is not required for a client with preterm labor who is discharged home.The client may benefit from rest and relaxation, but there is no evidence that light or noise affects preterm labor.

Choice D is wrong because eating small, frequent meals is not specific to a client with preterm labor who is discharged home.Eating small, frequent meals may help with nausea, heartburn, or blood sugar control, but it does not prevent preterm labor.

A. “To determine fetal lung maturity.”. B. “To assess the degree of fetal renal function.”. C. “To test the amniotic fluid glucose level.”. D. “To detect the presence of fetal congenital anomalies.”.

Correct Answer is A

Explanation

Choice A reason:
At 37 weeks, especially in gestational diabetes, fetal lungs may still be immature. Amniocentesis checks lung maturity to ensure the baby can breathe effectively if early delivery is needed due to fetal compromise.

Choice B reason:
Fetal renal function is not typically assessed through amniocentesis at term. Kidney function is monitored via ultrasound, not by analyzing amniotic fluid at 37 weeks.

Choice C reason:
Amniotic fluid glucose levels are not used to manage gestational diabetes. Maternal blood glucose is the standard for monitoring and treatment.

Choice D reason:
Congenital anomalies are usually detected earlier in pregnancy. By 37 weeks, the focus of amniocentesis is on delivery planning, not anomaly detection.

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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 client treated for preterm labor is to be discharged to home. Which instruction should a nurse include in this client’s discharge plan? The client should:.

Correct Answer is B

Explanation

A nurse is caring for a client who has gestational diabetes and is scheduled for an amniocentesis at 37 weeks of gestation due to suspected fetal compromise. What is the nurse’s best response to the client’s question as to why the amniocentesis test is being done?

Correct Answer is A

Explanation

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