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

Apply an ice pack to the affected area.

Offer a warm sitz bath.

Provide a squeeze bottle of antiseptic solution.

Place a hot pack to the perineum.

Answer and Explanation

The Correct Answer is A

The correct answer is A. Apply an ice pack to the affected area. Ice packs are recommended during the first 24 hours after birth to decrease swelling and help with pain.

Choice A reason: Applying an ice pack to the episiotomy site helps reduce swelling and provides pain relief. This is the standard care within the first 24 hours postpartum.

Choice B reason: A warm sitz bath is generally recommended after the first 24 hours following birth. It is not the best immediate action for unrelieved pain shortly after delivery.

Choice C reason: While maintaining cleanliness with a squeeze bottle of antiseptic solution is important for preventing infection, it does not provide the immediate pain relief needed for unrelieved episiotomy pain.

Choice D reason: Heat application, such as placing a hot pack, is not advised within the first 24 hours postpartum because it can increase the risk of swelling and bleeding.

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Correct Answer is D

Explanation

Choice A rationale:

Leaving the diaphragm in place for 4 hours following intercourse is incorrect. The diaphragm should be left in place for at least 6 hours after intercourse to ensure effectiveness in preventing pregnancy.

Choice B rationale:

Removing the diaphragm by catching the rim below the dome with the forefinger is incorrect. The diaphragm should be removed by hooking the finger behind the rim to avoid damaging the dome and ensure proper removal.

Choice C rationale:

Placing a thin layer of mineral oil on the diaphragm once per week is incorrect. Mineral oil can weaken latex diaphragms, reducing their effectiveness. Water-based lubricants are recommended for use with diaphragms.

Choice D rationale:

Placing 2 teaspoons of spermicide on the inside of the diaphragm before insertion is the correct technique. Spermicide helps to immobilize and kill sperm, enhancing the contraceptive effect of the diaphragm.

A. Prepare the equipment necessary to initiate an amnioinfusion. B. Administer oxygen at 10 L/min via a nonrebreather face mask. C. Discontinue the infusion of oxytocin. D. Place the client in a left lateral position.

Correct Answer is D

Explanation

Choice A reason:

Preparing for an amnioinfusion is not the first-line action. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.

Choice B reason:

Administering oxygen is a subsequent measure if initial interventions like repositioning do not improve the FHR. Oxygen is typically given at 8-10 L/min via a nonrebreather mask to increase fetal oxygenation.

Choice C reason:

Discontinuing oxytocin is important if the cause of decelerations is uterine hyperstimulation. However, repositioning the client should precede this action to quickly address potential umbilical cord compression.

Choice D reason:

This is the first action to take because it can quickly alleviate potential compression of the umbilical cord, which is often the cause of variable decelerations. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who is to start using a diaphragm for contraception. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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