A nurse is assessing a client who is 8 hours postpartum and multiparous.
Which of the following findings should alert the nurse to the client’s need to urinate?

Choice A rationale:

Amniotic fluid in the vaginal vault may indicate that the client's membranes have ruptured, but it does not necessarily mean

that labor has begun. Some women experience rupture of membranes before labor starts, while others do not experience it

until labor is well underway.

Additionally, it is not always possible to visually confirm the presence of amniotic fluid, as it may be mixed with other fluids or

present in small amounts.

Therefore, the presence of amniotic fluid alone is not a definitive sign of labor.

Choice B rationale:

Contractions are a common sign of labor, but they can also occur for other reasons, such as Braxton Hicks contractions or a

urinary tract infection.

To be considered a sign of true labor, contractions should be regular, becoming progressively stronger, longer, and closer

together.

A frequency of every 3 to 4 minutes is often suggestive of labor, but it is not always definitive.

Some women may experience contractions that are less frequent or more irregular and still be in labor.

Choice C rationale:

Cervical dilation is the most reliable sign of labor.

During labor, the cervix gradually opens to allow the baby to pass through the birth canal.

Cervical dilation is typically measured in centimeters, with 10 centimeters being considered full dilation.

Once the cervix has dilated to 3-4 centimeters, it is generally considered to be active labor.

This is because dilation of this degree usually indicates that the contractions are strong enough to effectively move the baby

through the birth canal.

Choice D rationale:

Pain just above the navel, also known as suprapubic pain, can be a sign of labor, but it is not a definitive one.

This type of pain can also be caused by other factors, such as bladder fullness or indigestion.

Additionally, not all women experience pain in this area during labor.

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 reducing blood flow to the area.

Additionally, it can separate the buttocks, further straining the incision site and hindering healing.

It's crucial to prioritize interventions that promote circulation and reduce pressure on the perineum to facilitate healing and

pain management.

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.

It's essential to allow the initial inflammatory phase of wound healing to subside before introducing heat therapy.

Choice D rationale:

Preparing a warm sitz bath is a helpful intervention for episiotomy pain, but it's generally recommended after the first 24

hours.

During the initial phase of healing, warm water can increase blood flow to the area, potentially leading to increased swelling

and discomfort.

It's often more beneficial to focus on cooling measures within the first 24 hours to reduce inflammation and promote comfort.

Choice B rationale:

Applying an ice pack to the perineum is the most appropriate action for the nurse to take in this scenario.

Cold therapy effectively reduces inflammation, swelling, and pain by constricting blood vessels and slowing nerve conduction.

It's a non-invasive and readily available intervention that can significantly improve comfort and promote healing in the early

stages of episiotomy recovery.

Key points:

Ice packs are generally recommended for the first 24 hours following an episiotomy to reduce pain and inflammation.

Heat therapy, such as sitz baths or heating lamps, can be helpful after the initial 24-hour period to promote circulation and

healing.

Pillows or cushions under the buttocks should be avoided as they can increase pressure on the perineum and worsen pain.

Nurses play a crucial role in educating clients about episiotomy care and providing appropriate pain relief measures.