A client is admitted to the postpartum unit with an ice pack to a right lateral episiotomy.
The client tells the practical nurse (PN), "That ice is cold! Take it off!" When responding to the client, which should the PN say is the most important reason for placing a cold pack to the perineum following a vaginal delivery?
The ice helps to reduce swelling of the episiotomy.
This is a nursing measure used to promote comfort.
It is not necessary since it is only used to prevent bruising.
The healthcare provider (HCP) uses this measure to control bleeding.
The Correct Answer is A
Choice A rationale
Applying a cold pack to the perineum after a vaginal delivery effectively reduces localized edema and inflammation. Cold therapy causes vasoconstriction, which decreases blood flow to the area, thereby minimizing fluid extravasation into the interstitial spaces and reducing swelling of the episiotomy site.
Choice B rationale
While cold packs do provide a degree of comfort by numbing nerve endings and reducing pain signals, their primary physiological benefit in the postpartum period is the reduction of swelling and inflammation, which indirectly contributes to comfort. Comfort is a secondary effect.
Choice C rationale
The statement is incorrect. Cold therapy is a recognized and effective intervention postpartum. While it may help reduce bruising by limiting subcutaneous bleeding, its most significant and immediate benefit relates to the reduction of swelling and pain.
Choice D rationale
While cold can induce vasoconstriction and thus potentially reduce bleeding, it is not the primary or most effective method for controlling significant postpartum hemorrhage. Fundal massage and uterotonics are the primary interventions for controlling postpartum bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Meconium is an infant's first stool, composed of amniotic fluid, lanugo, bile, and intestinal epithelial cells. Most infants pass meconium within the first 24 hours of life. Failure to pass meconium within 24 hours can indicate a bowel obstruction, such as Hirschsprung's disease or meconium ileus, necessitating immediate medical evaluation.
Choice B rationale
The amount of formula consumed by a 24-hour-old infant can vary. While adequate feeding is important, not finishing a 3 oz bottle at this early stage may not be as immediately concerning as the absence of meconium, as gastric capacity is still developing.
Choice C rationale
While three wet diapers indicate adequate hydration and renal function, which is positive, the absence of meconium stool is a more critical physiological assessment requiring urgent attention due to potential underlying pathology.
Choice D rationale
The use of a bulb syringe suggests the infant may have some respiratory secretions, which can be normal variations. This finding, while noted, does not carry the same level of immediate concern as the absence of meconium passage in a 24-hour-old.
Correct Answer is D
Explanation
Choice A rationale
A resting respiratory rate of 35 breaths/minute for a 4-month-old infant is within the normal range (typically 30-60 breaths/minute). Therefore, this finding alone does not indicate acute respiratory distress.
Choice B rationale
Bilateral bronchial breath sounds are normal findings when auscultated over the trachea. However, their presence over the peripheral lung fields can indicate consolidation, such as in pneumonia. While abnormal in the periphery, it is not an isolated sign of acute respiratory distress.
Choice C rationale
Diaphragmatic respirations, also known as abdominal breathing, are the predominant and normal breathing pattern in infants and young children due to the preferential use of the diaphragm for respiration. This is not a sign of respiratory distress.
Choice D rationale
Flaring of the nares is a significant clinical sign of increased work of breathing and respiratory distress in infants. It indicates that the infant is attempting to decrease airway resistance and maximize oxygen intake by dilating the nasal passages. This is a compensatory mechanism indicating respiratory compromise.
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