A nurse is caring for a client who has unrelieved episiotomy pain 8 hr following delivery. Which of the following actions should the nurse take?

Place a soft pillow under the client's buttocks.

Apply an ice pack to the perineum.

Position a heating lamp toward the episiotomy.

Prepare a warm sitz bath.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B: Apply an ice pack to the perineum. This is the recommended action for unrelieved episiotomy pain within the first 24 hours following delivery, as it helps reduce swelling and provide pain relief.

Choice A rationale:

Placing a soft pillow under the client’s buttocks may provide comfort, but it does not directly address the inflammation and pain associated with an episiotomy. It is not the primary intervention for unrelieved episiotomy pain shortly after delivery.

Choice B rationale:

Applying an ice pack to the perineum is a standard practice for reducing pain and swelling after an episiotomy. The cold temperature causes vasoconstriction, which can help to decrease swelling and provide pain relief. This is especially effective within the first 24 hours post-delivery.

Choice C rationale:

Positioning a heating lamp toward the episiotomy is not recommended immediately following the procedure, as heat can increase blood flow to the area, potentially worsening swelling and pain in the acute phase after the surgery.

Choice D rationale:

While a warm sitz bath may be beneficial for episiotomy pain relief, it is typically recommended after the initial 24-hour period post-delivery. In the first 24 hours, cold therapy is preferred to reduce acute inflammation and pain.

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Correct Answer is D

Explanation

The correct answer is choice d. Vastus lateralis.

Choice A rationale:

The deltoid muscle is not typically used for newborn injections because it is too small and underdeveloped, making it an inappropriate site for intramuscular injections in this age group.

Choice B rationale:

The dorsogluteal muscle is also not recommended for newborns due to the risk of injury to the sciatic nerve and the muscle’s underdevelopment.

Choice C rationale:

The ventrogluteal muscle, while a good site for older children and adults, is not commonly used for newborns because it is not as easily accessible and developed as the vastus lateralis.

Choice D rationale:

The vastus lateralis muscle, located on the anterolateral aspect of the thigh, is the preferred site for intramuscular injections in newborns. It is well-developed and provides a large muscle mass, making it the safest and most effective site for administering vitamin K.

A. The client is Rh positive and the newborn is Rh negative. B. The client is Rh negative and the newborn is Rh positive. C. The client is Rh negative and the newborn is Rh negative. D. The client is Rh positive and the newborn is Rh positive.

Correct Answer is B

Explanation

Choice A rationale:

If the client is Rh positive and the newborn is Rh negative, there is no indication for administering Rho(D) immune globulin. Rho(D) immune globulin is only given when the Rh-negative mother gives birth to an Rh-positive baby.

Choice B rationale:

This is the correct choice for administering Rho(D) immune globulin. When the mother is Rh negative and the newborn is Rh positive, there is a risk of Rh incompatibility. If the fetal blood enters the mother's circulation during delivery, her immune system may produce antibodies against Rh-positive blood cells, which can be harmful to future Rh-positive pregnancies. To prevent this, Rho(D) immune globulin is administered to the Rh-negative mother shortly after delivery.

Choice C rationale:

If both the mother and the newborn are Rh-negative, there is no risk of Rh incompatibility. Rho(D) immune globulin is not required in this situation.

Choice D rationale:

If both the mother and the newborn are Rh-positive, there is no risk of Rh incompatibility. Rho(D) immune globulin is not indicated in this case.

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A nurse is caring for a client who has unrelieved episiotomy pain 8 hr following delivery. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer vitamin K IM to a newborn. Into which of the following muscles should the nurse inject the medication?

Correct Answer is D

Explanation

A nurse is caring for a client who is postpartum. Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin?

Correct Answer is B

Explanation

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