A nurse is caring for a client who is 12 hours postpartum and has an episiotomy.
Which of the following actions should the nurse take?
Instruct the client to apply warm packs to the perineum every 8 hours.
Tell the client to apply antibiotic ointment to the perineal area four times per day.
Explain to the client how to dry her perineum by wiping with toilet tissue after each void.
Encourage the client to take a sitz bath twice per day.
The Correct Answer is D
Choice A rationale
Applying warm packs to the perineum is generally discouraged in the immediate postpartum period, especially within the first 24 hours, due to the risk of increasing swelling and discomfort. Cold applications are typically preferred initially to promote vasoconstriction, which helps to reduce edema and numb the area, offering greater pain relief.
Choice B rationale
Routine application of antibiotic ointment to an episiotomy is not standard practice unless there are signs of infection. Episiotomies are clean-contaminated wounds, and prophylactic antibiotic use is generally avoided to prevent the development of antibiotic resistance and disruption of the normal perineal flora. Aseptic wound care is prioritized.
Choice C rationale
Wiping the perineum with toilet tissue after voiding can introduce bacteria from the anal area into the healing episiotomy site, increasing the risk of infection. Perineal care should involve rinsing the area with warm water (e.g., using a peri-bottle) and patting it dry from front to back to minimize bacterial contamination and promote healing.
Choice D rationale
Encouraging the client to take a sitz bath twice per day is beneficial for episiotomy care. The warm water promotes vasodilation, increasing blood flow to the perineal area, which aids in healing and reduces discomfort. It also helps to keep the area clean and can soothe irritated tissues, facilitating recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
? Rationale for Correct Answers
2 oz of formula is appropriate as the first intervention because the newborn is experiencing symptomatic hypoglycemia (glucose 35 mg/dL) and had difficulty latching during breastfeeding. Formula provides a rapid source of glucose to correct hypoglycemia when breastfeeding is insufficient or ineffective. The goal is to raise blood glucose above 45 mg/dL to prevent neurologic injury.
Skin-to-skin contact supports thermoregulation, glucose stabilization, and neurobehavioral organization. It enhances bonding and promotes successful breastfeeding, which is essential for ongoing glucose maintenance. After feeding, skin-to-skin helps maintain euglycemia and calm the newborn.
❌ Rationale for Incorrect Response 1 Options
Morphine per protocol is used for neonatal abstinence syndrome (NAS), not hypoglycemia. There is no history of maternal opioid use or signs of withdrawal (e.g., hypertonia, sneezing, diarrhea).
Oxygen via nasal cannula is indicated for respiratory distress or hypoxia. This newborn has normal respiratory rate (45/min) and unlabored breathing, so oxygen is unnecessary.
Swaddling with legs flexed is a comfort measure, not a treatment for hypoglycemia. While it may reduce energy expenditure, it does not address the underlying glucose deficit.
❌ Rationale for Incorrect Response 2 Options
Dextrose 50% is hypertonic and contraindicated in neonates due to risk of vein damage and rebound hypoglycemia. Oral feeding is preferred for mild hypoglycemia; IV dextrose (usually D10W) is reserved for severe or refractory cases.
Naloxone is used to reverse opioid-induced respiratory depression. There is no evidence of opioid exposure or respiratory compromise in this newborn.
Antibiotics are used for suspected sepsis. This newborn is afebrile, alert, and without signs of infection.
? Take-Home Points
- Symptomatic neonatal hypoglycemia should be treated promptly with oral feeding (breast milk or formula).
- Formula is appropriate when breastfeeding is ineffective or delayed.
- Skin-to-skin contact supports glucose regulation and promotes breastfeeding success.
- IV dextrose is reserved for severe or persistent hypoglycemia unresponsive to feeding.
Correct Answer is B
Explanation
Choice A rationale
Vesicles on the skin, lips, and around the eyes are characteristic findings associated with herpes simplex virus infections, not Candida albicans. Herpes simplex presents with fluid-filled lesions and can be transmitted vertically during birth, manifesting in localized or disseminated forms in the neonate.
Choice B rationale
White patches on the tongue that cannot be removed are a classic sign of oral candidiasis, commonly known as thrush. This fungal infection, caused by *Candida albicans*, involves adhesion and proliferation of yeast on the mucous membranes, forming adherent pseudomembranous plaques.
Choice C rationale
Edematous red conjunctivae are typical manifestations of conjunctivitis, which can be caused by bacterial or viral infections, such as *Chlamydia trachomatis* or *Neisseria gonorrhoeae*, acquired during passage through the birth canal. This finding is not indicative of *Candida albicans* infection.
Choice D rationale
A temperature of 37.5° C (99.5° F) is within the normal range for a newborn, which typically falls between 36.5° C and 37.5° C (97.7° F and 99.5° F). While infections can cause fever, this specific temperature alone does not definitively indicate an infection with *Candida albicans* or any other pathogen.
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