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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse should report a blood urea nitrogen (BUN) level of 35 mg/dL to the provider. BUN measures the amount of nitrogen in the blood and is used to assess kidney function. An elevated BUN can indicate impaired renal function, which is a concern in preeclampsia, as it may signify reduced blood flow to the kidneys.
Choice B rationale:
Hemoglobin (Hgb) level of 15 mg/dL is within the normal range for pregnancy (normal range: 11-15 g/dL), so there is no need to report it to the provider.
Choice C rationale:
Bilirubin level of 0.6 mg/dL is within the normal range (normal range: 0.2-1.3 mg/dL), so there is no need to report it to the provider.
Choice D rationale:
Hematocrit (Hct) level of 37% is within the normal range for pregnancy (normal range: 33- 45%), so there is no need to report it to the provider.
Correct Answer is D
Explanation
A. Vitamin E requirements do not significantly increase during pregnancy.
B. While vitamin D is important for calcium absorption, the recommended intake does not increase during pregnancy.
C. Fiber intake is beneficial for digestion but does not have increased requirements specific to pregnancy.
D. Calcium intake should be increased to support fetal bone and teeth development.
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