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 ["A","B","E","F"]
Explanation
A. Call the lactation consultant to visit the patient
Rationale: A lactation consultant is a specialized professional who can provide expert guidance on breastfeeding techniques and troubleshooting latching issues. They can offer personalized assistance and support to ensure proper latch and feeding.
B. Encourage and support the mother's desire/intention and include the partner in the conversation
Rationale: Providing emotional support and encouragement is crucial. Including the partner helps create a supportive environment for the mother and ensures that everyone is on the same page regarding breastfeeding goals and practices.
E. Check for audible swallowing and a comfortable (non-painful) suck
Rationale: Ensuring that the baby is swallowing and that the mother is not experiencing pain during feeding indicates that the latch may be correct. This helps confirm that the baby is feeding effectively and that the mother is comfortable.
Not Recommended:
C. Give the mother a bottle of formula to supplement
Rationale: Introducing formula supplementation is not necessary if the goal is exclusive breastfeeding. This step might undermine the mother's confidence or interfere with the baby's ability to latch properly.
D. Help the mother shove her nipple in the baby's mouth
Rationale: This approach can cause discomfort and may not address the underlying issue of improper latching. It is better to use techniques that encourage a natural and comfortable latch.
Note:
F. Assist with proper positioning and latch techniques"
Rationale:Proper positioning ensures the baby is comfortably aligned with their head in line with their body, and the baby is brought to the breast, not vice versa.
A good latch involves the baby opening their mouth wide to take in the nipple and a portion of the areola, which helps with milk transfer and reduces discomfort. Proper latch prevents pain and supports milk production.
Correct Answer is C
Explanation
Choice A: Prolapsed cord is not a likely complication, as it is characterized by a sudden onset of severe variable decelerations of the fetal heart rate and a visible or palpable cord in the vaginA. The nurse should identify a prolapsed cord as a medical emergency and perform immediate interventions to relieve the cord compression and deliver the fetus.
Choice B: Premature rupture of membranes is not a likely complication, as it is characterized by a gush or a trickle of clear or yellowish fluid from the vagina and a positive nitrazine or fern test. The nurse should identify premature rupture of membranes as a risk factor for infection and monitor the fetal heart rate and the maternal temperaturE.
Choice C: Abruptio placentae is a likely complication, as it is characterized by continuous abdominal pain and dark red vaginal bleeding and a board-like abdomen. The nurse should identify abruptio placentae as a life-threatening condition that involves the premature separation of the placenta from the uterine wall and can cause fetal distress and maternal hemorrhagE.
Choice D: Placenta previa is not a likely complication, as it is characterized by painless bright red vaginal bleeding and a soft and relaxed uterus. The nurse should identify placenta previa as a condition that involves the abnormal implantation of the placenta near or over the cervical os and can cause fetal hypoxia and maternal hemorrhagE.
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