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 B

Explanation

Choice A rationale:

Assisting the client to a sitz bath is not the priority action in this situation. The client has soaked two perineal pads in the past 30 minutes, indicating excessive bleeding, which requires immediate attention.

Choice B rationale:

Assessing the client's uterine tone is essential to determine if the uterus is contracting appropriately. Uterine atony, where the uterus fails to contract after childbirth, is a common cause of postpartum hemorrhage. Assessing the tone helps identify this issue and allows for timely interventions.

Choice C rationale:

Encouraging the client to breastfeed may have benefits such as promoting uterine contractions through oxytocin release. However, the priority in this scenario is addressing the potential postpartum hemorrhage.

Choice D rationale:

Applying an ice pack to the client's perineum may provide comfort, but it does not address the concerning symptom of excessive bleeding and potential postpartum hemorrhage.

A. Petroleum jelly. B. Pre-moistened towelettes. C. Povidone-iodine. D. Silver sulfadiazine.

Correct Answer is A

Explanation

Choice A rationale:

Petroleum jelly is a common recommendation to apply during diaper changes for circumcised newborns. It acts as a barrier between the diaper and the healing penis, reducing friction and preventing the diaper from sticking to the sensitive area. This can help promote better healing and prevent discomfort for the newborn.

Choice B rationale:

Pre-moistened towelettes are not typically recommended for application on the penis of a circumcised newborn during diaper changes. These towelettes may contain chemicals or irritants that could potentially irritate the delicate skin of the healing area.

Choice C rationale:

Povidone-iodine is an antiseptic solution often used to disinfect the skin before procedures or surgeries. However, it is not recommended for routine use on the penis of a circumcised newborn during diaper changes as it may be too harsh for the healing skin.

Choice D rationale:

Silver sulfadiazine is a topical antimicrobial agent used for treating burns and certain infections. However, it is not indicated for use on a circumcised newborn's penis during diaper changes. The healing process after circumcision does not usually involve infections that require this type of treatment.

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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 caring for a client who had a vaginal birth 2 hr ago and has soaked two perineal pads in the past 30 min. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is providing discharge instructions to parents of a circumcised newborn. To prevent diaper adherence to the penis, what will be recommended to apply during diaper changes?

Correct Answer is A

Explanation

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