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 A

Explanation

The correct answer is choice A. A patient who weighed less than 5 lb (2,268 gm) at birth is at risk for having an infant with intrauterine growth retardation (IUGR).This is because low birth weight is a possible indicator of genetic factors or placental insufficiency that can affect fetal growth.

Choice B is wrong because an ectopic pregnancy one year ago does not increase the risk of IUGR.An ectopic pregnancy is when the fertilized egg implants outside the uterus, usually in the fallopian tube.It does not affect the placental function or fetal development in a subsequent pregnancy.

Choice C is wrong because a mitral valve prolapse does not increase the risk of IUGR.

A mitral valve prolapse is when the valve between the left atrium and left ventricle of the heart does not close properly.It usually does not cause any symptoms or complications during pregnancy, unless it is associated with severe regurgitation or arrhythmias.

Choice D is wrong because the father’s age of 42 years old does not increase the risk of IUGR.The father’s age may affect the risk of chromosomal abnormalities or congenital anomalies in the fetus, but not the fetal growth.

Some of the other risk factors for IUGR include maternal smoking, alcohol, or drug use, medical conditions like anemia or lupus, infections such as rubella or syphilis, carrying twins or multiples, high blood pressure, gestational diabetes, and placenta problems.

A. Decrease in body temperature. B. Maternal cardiac arrhythmias. C. Urinary retention. D. Insufficient relaxation of the uterus between contractions.

Correct Answer is D

Explanation

The correct answer is choice D. Insufficient relaxation of the uterus between contractions.This is also known astachysystoleorhyperstimulation, which can cause fetal distress and uterine rupture.Oxytocin is a hormone that stimulates uterine contractions, but it can also cause them to be too strong or too frequent if given in high doses or for too long.

Choice A is wrong because oxytocin does not decrease body temperature.

Choice B is wrong because oxytocin does not cause maternal cardiac arrhythmias.

Choice C is wrong because oxytocin does not cause urinary retention.

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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

A patient who is 17 weeks pregnant shares several pieces of information with the nurse. Which statement made by the patient would indicate the patient is at risk for having an infant with intrauterine growth retardation (IUGR)?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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