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A nurse is caring for a client who is postpartum and has an episiotomy.
Which of the following actions should the nurse take?

A.

Instruct the client to apply anesthetic spray to the site three to four times a day.

B.

Encourage the client to change perineal pads at least three times a day.

C.

Assist the client to fill the squeeze bottle with cold water to perform perineal care.

D.

Alternate warm and ice packs to the site every 2 hours for the first 24 hours postpartum.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Instructing the client to apply anesthetic spray to the site three to four times a day is incorrect. While anesthetic sprays can help with pain relief, it's more important to manage swelling and discomfort with a combination of methods, including ice packs and perineal care.

Choice B rationale

Encouraging the client to change perineal pads at least three times a day is insufficient. Pads should be changed more frequently to maintain hygiene and prevent infection.

Choice C rationale

Assisting the client to fill the squeeze bottle with cold water to perform perineal care is incorrect. While perineal care is important, cold water is not typically recommended as it may not provide comfort and might even cause discomfort.

Choice D rationale

Alternating warm and ice packs to the site every 2 hours for the first 24 hours postpartum is correct. This method helps manage pain and swelling effectively, promoting healing and comfort for the client.


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Related Questions

Correct Answer is []

Explanation

Hypoglycemia is most likely given the newborn's jitteriness, weak cry, and mottled extremities, all of which are signs of low blood sugar. The newborn's large birth weight (4,366 g) further increases the risk of hypoglycemia. Immediate feeding is crucial to increase blood sugar levels, and phototherapy can help manage any potential jaundice, which is often associated with hypoglycemia.

Feeding the newborn is essential to provide glucose and stabilize blood sugar levels. Monitoring phototherapy ensures effective treatment of jaundice, which often coexists with hypoglycemia in newborns.

Assessing skin integrity is necessary to prevent complications from jaundice and ensure proper phototherapy response. Monitoring bilirubin levels helps track jaundice severity and the effectiveness of treatment.

Kernicterus, a severe form of jaundice, is less likely because the newborn's symptoms primarily indicate hypoglycemia. Neonatal Abstinence Syndrome, due to maternal drug use, typically involves different symptoms such as irritability, excessive crying, and poor feeding. Congenital Syphilis is ruled out as the mother was treated and tests for syphilis are negative.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

The nurse should prepare to reinforce teaching with the client about a low-sodium diet with a prescription of nifedipine.

So, the correct options are:

  1. C. low-sodium diet
  2. A. nifedipine

Explanation:

  1. Low-sodium diet:
    • The client has a history of obesity and hypertension, which are both managed effectively with a low-sodium diet. Reducing sodium intake can help lower blood pressure and reduce the risk of complications.
  2. Nifedipine:
    • The client has been prescribed nifedipine, which is a medication used to treat high blood pressure. This aligns with her history of hypertension and the current elevated blood pressure readings.

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