A client delivered a 10-pound baby girl vaginally 14 hours ago. The nurse applies an icepack to the perineum. The nurse understands that application of ice is used to:
Decrease lochia
Provide painful effect
Decrease edema
Cleanse the perineum
The Correct Answer is C
A. Ice application does not decrease lochia. Lochia is the normal postpartum vaginal discharge consisting of blood, mucus, and uterine tissue. Its flow is regulated by uterine contractions and involution, not by external cooling. Ice has no impact on the volume, color, or duration of lochia.
B. Ice does not provide a painful effect; rather, it provides a pain-relieving or numbing effect by slowing nerve conduction in the area. While clients may feel temporary numbness, the purpose is analgesia, not inducing pain. The cold temperature can help reduce discomfort from perineal trauma, such as lacerations, episiotomies, or swelling.
C. Decreasing edema is the primary purpose of applying ice to the perineum after vaginal delivery. Ice causes vasoconstriction, which limits blood flow to the tissues, thereby reducing swelling and inflammation. Edema is common in the first 24 hours postpartum, especially after traumatic births, large babies, or prolonged pushing, and can contribute to pain and discomfort. Applying ice also helps minimize hematoma formation and can improve the client’s comfort during the early postpartum period. Ice therapy is typically recommended for 15–20 minutes at a time in the immediate postpartum period for optimal effectiveness.
D. Ice does not cleanse the perineum. Perineal hygiene is maintained through separate interventions such as peri-bottle rinsing, sitz baths, or gentle cleansing with warm water. Ice therapy only addresses swelling and discomfort, not infection control or cleanliness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Eliciting the Moro reflex to wake the baby is unsafe and unnecessary. This method involves startling the infant, which can cause distress and may result in injury to the nipple, infant’s gums, or palate. It does not address the correct technique for breaking suction safely.
B. Pulling the breast or nipple directly from the baby’s mouth can lead to significant nipple trauma, including cracking, bleeding, and pain, and may also injure the infant’s mouth. This method is considered unsafe and is strongly discouraged in breastfeeding education.
C. Breaking the suction by gently inserting a clean finger into the corner of the infant’s mouth is the recommended technique. This action releases the latch safely, prevents nipple trauma, and allows the infant to unlatch without discomfort. It ensures that both the mother and baby remain safe during breastfeeding, and it supports proper feeding practices.
D. Relying on a popping sound as an indicator of safe breast removal is unreliable and can be misleading. Attempting to remove the breast based on sound alone may result in abrupt or forceful removal, causing pain or injury to the mother’s nipple and the infant’s oral tissues.
Correct Answer is C
Explanation
A. While some guidelines suggest that alternating days can reduce gastrointestinal side effects and improve absorption for certain formulations, the primary recommendation for iron absorption focuses on enhancers and inhibitors of absorption, not timing. Therefore, this is not the most important instruction for effectiveness.
B. Calcium in milk inhibits iron absorption, making it less effective when taken together. Iron supplements should not be taken with dairy products.
C. Vitamin C (ascorbic acid), found in orange juice, enhances the absorption of non-heme iron, which is the type found in most oral iron supplements. Taking iron with vitamin C–rich fluids significantly improves the effectiveness of supplementation.
D. Tea contains tannins, which inhibit iron absorption, reducing the effectiveness of the supplement. It is recommended to avoid tea, coffee, and high-calcium foods near the time of taking iron supplements.
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