The practical nurse (PN) views the mid-line episiotomy of a client who reports pain in her stitches. Which action should the PN take first?
Apply an ice pack for 20 minutes to the episiotomy.
Observe suture line for separation and hematoma formation.
Initiate daily warm sitz baths during onset of pain.
Check medication administration record for last PRN analgesic.
The Correct Answer is B
A. Applying an ice pack can help manage pain and reduce swelling, but it is not the immediate priority. It is essential first to assess for complications that may require different interventions.
B. Observing the suture line for separation and hematoma formation is the first step in managing pain. Identifying possible complications like suture line issues or hematomas will guide the appropriate treatment.
C. Initiating warm sitz baths is beneficial for pain management and healing, but it should be done after assessing the episiotomy for potential complications. It is a supportive measure rather than an immediate assessment action.
D. Checking the medication administration record is relevant for managing pain but is secondary to assessing the condition of the episiotomy site. The first priority is to evaluate the site for any physical complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"F","dropdown-group-3":"D"}
Explanation
- Dark Room Lighting
Consistent with Elder Mistreatment: A dark, uninviting environment can indicate neglect or lack of proper care. It may reflect poor living conditions or neglect of the client's environment, which can be a sign of mistreatment. - Malnutrition
Consistent with Elder Mistreatment: The client’s low weight (98 lb) relative to her height (5 ft 4 in) suggests potential malnutrition. Malnutrition can be a sign of neglect, as the client might not be receiving adequate food or nutrition, which is a form of mistreatment. - Pressure Injuries
Consistent with Elder Mistreatment: Although the pressure injuries have closed, the presence of Stage II pressure ulcers in the past indicates a lack of proper care and attention to the client’s needs. Pressure ulcers are a common sign of neglect in care settings.
Not Consistent with Elder Mistreatment
- Poor Hygiene
Not Consistent: The client appears clean and healthy with no issues in skin condition or oral hygiene, so this is not a sign of mistreatment. - Bilateral Leg Edema
Not Consistent: While edema might be a concern in heart failure management, it is not specifically indicative of elder mistreatment. - Short Term Memory Loss
Not Consistent: Short-term memory loss is not necessarily a sign of mistreatment; it could be related to aging or medical conditions.
Correct Answer is A
Explanation
A. Folic acid deficiency is the most significant maternal factor associated with the development of spina bifida occulta. Adequate folic acid intake before and during pregnancy is crucial for preventing neural tube defects.
B. Preeclampsia is a serious pregnancy complication but does not have a direct link to spina bifida occulta compared to the impact of folic acid deficiency.
C. A short interval between pregnancies is associated with other risks but is not a known direct cause of spina bifida occulta.
D. Tobacco use has various adverse effects on pregnancy and fetal development but is not as directly linked to the risk of spina bifida occulta as folic acid deficiency.
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