A nurse is caring for a client who has unrelieved episiotomy pain 8 hours following delivery.
Which of the following actions should the nurse take?

Choice A rationale:

Maintaining the client in the lithotomy position is not recommended during labor, particularly for extended periods.

It can impede blood flow, increase pressure on the sacral nerves, and potentially lead to discomfort, fatigue, and decreased

fetal oxygen supply.

It's essential to encourage position changes and ambulation during labor to promote comfort, fetal descent, and optimal blood

flow.

Choice B rationale:

Checking the client's temperature every 8 hours is not a priority intervention for a client in the active phase of labor following

an amniotomy.

While monitoring for infection is important, it's typically done more frequently, such as every 2-4 hours, if there are concerns

or risk factors.

More frequent temperature checks would be indicated if the client develops signs of infection, such as fever, chills, or foul-

smelling amniotic fluid.

Choice D rationale:

Reminding the client to bear down with each contraction is not appropriate during the active phase of labor.

Early bearing down can lead to maternal fatigue and potential complications like cervical lacerations, decreased fetal oxygen

supply, and perineal trauma.

It's generally recommended to encourage spontaneous pushing efforts when the client feels the urge to bear down, which

typically occurs during the second stage of labor when the cervix is fully dilated.

Choice C rationale:

Encouraging the client to empty the bladder every 2 hours is a crucial nursing intervention for a client in labor.

Here's why:

Preventing bladder distention: A full bladder can obstruct the fetal descent, prolong labor, and increase discomfort.

Promoting uterine contractions: An empty bladder allows more room for the uterus to contract effectively, facilitating labor

progress.

Reducing the risk of infection: Frequent bladder emptying helps prevent urinary tract infections, which can be more common

during labor due to catheterization or perineal trauma.

Enhancing comfort: A full bladder can cause significant pressure and discomfort for the laboring client. Emptying the bladder

regularly promotes relaxation and a sense of well-being.

Choice A rationale:

Placing a soft pillow under the client's buttocks is not recommended for episiotomy pain relief. It can actually increase pain by placing pressure on the perineum and impeding blood flow to the area. This can hinder healing and prolong discomfort.

Additionally, it can separate the buttocks, potentially decreasing venous return and further exacerbating pain.

Choice C rationale:

Positioning a heating lamp toward the episiotomy is not appropriate within the first 24 hours following delivery. Heat application during this early stage can increase inflammation and swelling, potentially worsening pain and delaying healing.

Heat therapy is typically recommended after 24 hours to promote circulation and tissue repair, but it's crucial to apply it at the appropriate time.

Choice D rationale:

Preparing a warm sitz bath is a common comfort measure for postpartum perineal care, but it's generally recommended after