A nurse is caring for a client who has unrelieved episiotomy pain 8 hours following delivery. Which of the following actions should the nurse take? (Select onE.:
Place a soft pillow under the client's buttocks.
Prepare a warm sitz batH.
Position a heating lamp toward the episiotomy.
Apply an ice pack to the perineum.
The Correct Answer is D
Choice A: Placing a soft pillow under the client's buttocks is not an effective action, as it can increase the pressure and the swelling on the perineal area and worsen the pain. The nurse should avoid placing anything under the client's buttocks and encourage the client to lie on the side or sit on a firm surfacE.
Choice B: Preparing a warm sitz bath is not an appropriate action, as it can increase the blood flow and the inflammation on the perineal area and worsen the pain. The nurse should avoid using heat on the perineum for the first 24 hours after delivery and use cold therapy insteaD.
Choice C: Positioning a heating lamp toward the episiotomy is not an appropriate action, as it can cause burns and infections on the perineal area and worsen the pain. The nurse should avoid using heat on the perineum for the first 24 hours after delivery and use cold therapy insteaD.
Choice D: Applying an ice pack to the perineum is an effective action, as it can reduce the blood flow and the inflammation on the perineal area and relieve the pain. The nurse should apply an ice pack wrapped in a towel or a disposable cold pack to the perineum for 10 to 20 minutes every 2 to 4 hours for the first 24 hours after delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is not the correct finding because it indicates a possible uterine rupture, which is a complication of placental abruption, not placenta previA. Placental abruption is the premature separation of the placenta from the uterine wall, which can cause severe pain, bleeding, and fetal distress.
Choice B reason: This is the correct finding because it indicates a possible placenta previa, which is the implantation of the placenta over or near the cervical os. Placenta previa can cause painless bleeding that increases as the cervix dilates and effaces.
Choice C reason: This is not the correct finding because it indicates a possible onset of labor, which is not a complication of placenta previA. Labor can cause contractions, bloody show, and cervical changes, but it does not cause excessive bleeding or pain.
Choice D reason: This is not the correct finding because it indicates a possible marginal placenta previa, which is a less severe form of placenta previa that does not cover the cervical os. Marginal placenta previa can cause mild bleeding and pain, but it is not as dangerous as a complete or partial placenta previA.
Correct Answer is A
Explanation
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