A client who has just given birth to a healthy newborn required an episiotomy. Which action would the nurse implement immediately after birth to decrease the client's pain from the procedure?

Apply an ice pack to the site.

Offer warm blankets.

Offer a warm sitz bath.

Encourage the woman to void

Answer and Explanation

The Correct Answer is A

A. Ice helps to reduce swelling, numb the area, and relieve pain during the first 24 hours after an episiotomy. Applying ice immediately after birth can help minimize discomfort and inflammation.

B. Offer warm blankets may provide comfort but will not specifically target pain relief or swelling at the site of the episiotomy.

C. Offer a warm sitz bath is beneficial for postpartum healing and pain relief but should not be used immediately after the procedure. Warm sitz baths are typically recommended after the first 24 hours to promote relaxation and improve blood circulation.

D. Encourage the woman to void is important for overall comfort and bladder function but will not directly address the pain from the episiotomy.

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Correct Answer is ["A","D"]

Explanation

A. Dark red vaginal bleeding is often seen in placental abruption. The blood from an abruption is typically dark red (indicating that it is older blood) and may be mixed with amniotic fluid, making it more challenging to assess. However, the bleeding can sometimes be concealed, especially in complete abruption or retroplacental hemorrhage, where blood accumulates behind the placenta.

B. Absence of pain is incorrect. In fact, placental abruption is typically associated with abdominal pain, which can be severe and often comes on suddenly. Pain occurs due to the detachment of the placenta from the uterine wall and subsequent irritation or bleeding into the uterine cavity.

C. Insidious onset is incorrect. Placental abruption usually has a sudden or acute onset of symptoms, such as vaginal bleeding and abdominal pain. An insidious onset would be more suggestive of other conditions, such as placenta previa.

D. Absent fetal heart tones is a critical finding. Placental abruption can cause fetal distress or fetal death, especially if the abruption is severe. Absent fetal heart tones are a sign of fetal compromise or death resulting from the disruption of placental blood flow.

A. evidence that the newborn is becoming chilled. B. a good time to initiate breast-feeding. C. the period of decreased responsiveness preceding sleep. D. A sign that the infant is being overstimulated.

Correct Answer is B

Explanation

A. Evidence that the newborn is becoming chilled would typically include signs such as cool skin, mottling, or acrocyanosis ,not active behaviors like head movement and eye contact.
B. A good time to initiate breast-feeding is correct. The described behaviors ,eye contact, head movement, and tongue thrusting, are characteristic of the first period of reactivity, which occurs within the first 30 minutes after birth. During this time, the newborn is alert, responsive, and exhibits strong rooting and sucking reflexes, making it an ideal window to begin breastfeeding.
C. The period of decreased responsiveness preceding sleep typically occurs after the first period of reactivity and is marked by reduced activity and interest in feeding, not alert behaviors.
D. A sign that the infant is being overstimulated would usually involve signs like gaze aversion, hiccupping, or flailing ,not purposeful movements or eye contact.

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A client who has just given birth to a healthy newborn required an episiotomy. Which action would the nurse implement immediately after birth to decrease the client's pain from the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse suspects that a pregnant client may be experiencing a placental abruption based on assessment of which finding? Select all that apply.

Correct Answer is ["A","D"]

Explanation

Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as:

Correct Answer is B

Explanation

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