A patient had an episiotomy during her delivery. Which nursing action should be included in her plan of care for the first 12 hours?

Have her do Kegel exercises once an hour.

Apply ice to her perineal area.

Keep her hips slightly elevated.

Observe her perineal area for signs of infection.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B. Apply ice to her perineal area. This is because ice can help reduce swelling and pain in the episiotomy wound, which is a cut made in the tissue between the vagina and anus during childbirth. Ice should be applied for the first 24 to 48 hours after delivery.

Choice A is wrong because Kegel exercises, which involve contracting and relaxing the pelvic floor muscles, are not recommended for the first 12 hours after an episiotomy. They can increase blood flow and inflammation in the area, and may interfere with healing.

Choice C is wrong because keeping her hips slightly elevated can cause pressure on the episiotomy wound and increase discomfort. It can also affect blood circulation and drainage in the area.

Choice D is wrong because observing her perineal area for signs of infection is not a nursing action that should be included in her plan of care for the first 12 hours. Infection is rare in episiotomy wounds, and signs of infection usually appear after 24 hours or later. However, the nurse should teach the patient how to keep the area clean and dry, and when to report any signs of infection, such as fever, pus, or foul-smelling discharge.

Normal ranges for episiotomy healing are:

• Stitches dissolve within 2 to 4 weeks

• Pain and swelling subside within a few days to a week

• Wound heals completely within 4 to 6 weeks

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Correct Answer is D

Explanation

The correct answer is choice D. Leaning slightly backwards when walking can increase the curvature of the lower spine and worsen back pain.

The other choices are helpful methods to alleviate back pain during pregnancy.

Choice A is correct because pelvic tilt exercises can strengthen the abdominal muscles and reduce the strain on the lower back.

Choice B is correct because wearing shoes with low heels can improve posture and balance and prevent excessive arching of the lower back.

Choice C is correct because sleeping on the side with a pillow beneath the knees can support the spine and pelvis and relieve pressure on the lower back.

Normal ranges for back pain during pregnancy vary depending on the individual, but some common factors that can affect it are weight gain, hormonal changes, center of gravity shift, stress and muscle separation.

A. “Your labor may slow down if you receive an epidural now.”. B. “You need to be at least eight centimeters dilated prior to receiving an epidural.”. C. “You will need to be catheterized prior to receiving an epidural.”. D. “Your baby needs to be at zero station before you can have an epidural.”.

Correct Answer is A

Explanation

The correct answer is choice A. “Your labor may slow down if you receive an epidural now.” An epidural is a type of regional anesthesia that blocks pain in a specific area of the body.

It can be used to reduce pain during labor and delivery.

However, an epidural can also have some side effects, such as lowering blood pressure, causing fever, and slowing down labor progress.

Therefore, it is usually recommended to wait until the cervix is at least 4 to 5 cm dilated and the contractions are strong and regular before receiving an epidural.

Choice B is wrong because there is no fixed rule about how dilated the cervix needs to be before receiving an epidural.

Some women may receive an epidural earlier or later than others, depending on their pain level, medical history, and preferences.

Choice C is wrong because catheterization is not a prerequisite for receiving an epidural.

Catheterization is the insertion of a tube into the bladder to drain urine.

It may be done after receiving an epidural because the anesthesia can affect the ability to urinate.

However, it is not required before receiving an epidural.

Choice D is wrong because the station of the baby does not determine when a woman can have an epidural.

The station of the baby refers to how far the baby has descended into the pelvis.

It is measured in relation to the ischial spines, which are bony landmarks in the pelvis.

A positive station means that the baby is below the spines, while a negative station means that the baby is above the spines.

Zero station means that the baby is at the level of the spines.

The station of the baby does not affect the administration of an epidural, as long as there are no other complications or contraindications.

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A patient had an episiotomy during her delivery. Which nursing action should be included in her plan of care for the first 12 hours?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a class for women in the second trimester of pregnancy, the nurse discusses methods to alleviate back pain. Which statement by a class member would indicate the need for additional instruction?

Correct Answer is D

Explanation

A nurse is caring for a primigravida whose cervix is 2 cm dilated, 75% effaced, and the fetal presenting part is at +2 station. The patient says to the nurse, “I want an epidural now.Why won’t someone give me an epidural?” Which response is most appropriate for the nurse to make?

Correct Answer is A

Explanation

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