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

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

The correct answer is choice D. Apply petrolatum to the patient’s perineum.This is because petrolatum can help soothe and protect the perineal area, which may be swollen, bruised, or have stitches after a vaginal delivery.Applying petrolatum can also prevent the pad from sticking to the wound and causing more pain.

Choice A is wrong because observing the patient for vaginal discharge of bright red blood is not a specific action for perineal care.Bright red blood may indicate postpartum hemorrhage, which requires immediate medical attention.

Choice B is wrong because assessing the patient’s vaginal tone is not a priority action for perineal care.Vaginal tone may be reduced after childbirth due to stretching of the pelvic floor muscles, but this can improve with time and exercises.

Choice C is wrong because massaging the patient’s perineum is not recommended for perineal care.Massaging the perineum may cause more trauma and discomfort to the area, especially if there are stitches or hemorrhoids.Massaging the fundus (the top of the uterus) may be done to help it contract and prevent bleeding, but this is different from massaging the perineum.

A. Quickening. B. Uterine enlargement. C. Urinary frequency. D. Presence of human chorionic gonadotropin (hCG) in blood.

Correct Answer is D

Explanation

The correct answer is choice D. Presence of human chorionic gonadotropin (hCG) in blood.This is apositive sign of pregnancythat can only be attributed to a fetus.hCG is a hormone produced by the placenta that can be detected in blood or urine tests.

Choice A. Quickening.This is apresumptive sign of pregnancythat is based on the woman’s report of feeling fetal movements in her lower abdomen.This can occur at 16 weeks for second time moms and around 20 weeks for first time moms.However, this sign is not conclusive as other conditions can cause similar sensations.

Choice B. Uterine enlargement.This is aprobable sign of pregnancythat can be observed by the nurse or doctor through palpation.However, this sign does not mean 100% that a baby is growing in the uterus as it can be due to other causes such as fibroids or tumors.

Choice C. Urinary frequency.This is apresumptive sign of pregnancythat is based on the woman’s report of needing to urinate more often than usual.This can be caused by hormonal changes and increased blood volume during pregnancy.However, this sign is not definitive as other conditions such as urinary tract infections or diabetes can also cause frequent urination.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 the postpartal admission assessment, the nurse notes that a patient’s perineum appears edematous and ecchymotic. Based on this finding, which action should the nurse take?

Correct Answer is D

Explanation

A client is at the antepartal clinic for a pregnancy test.Which finding, if present, would be considered a positive sign of pregnancy?

Correct Answer is D

Explanation

A client with a history of diabetes mellitus (T1 D) is 32 weeks pregnant.The client returns to the clinic for a scheduled ultrasound and non-stress test. What should the nurse expect the non-stress test to determine?

The nurse suspects drug abuse in a patient admitted with no prenatal care and a diagnosis of abruptio placentae.Which question would elicit the most information from the patient concerning the suspected drug use?

A 38-year-old primigravida returns to the clinic at 16 weeks gestation for an alpha-fetoprotein test.She asks a nurse, "Why do lI need this test?".Which response would be most appropriate for the nurse to make?

A nurse is observing the internal fetal monitor readings of a laboring client.The fetal heart rate is between 130 and 138 beats per minute, with moderate beat-to-beat variability. How should the nurse interpret this finding?

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)?

The physician prescribes prostaglandin (PGE2) gel for a patient being admitted for induction of labor. Which finding would best indicate that the prostaglandin gel is effective?

A client asks a nurse about breastfeeding, and the nurse discusses the topic with her. Which statement by the client indicates she needs further instruction?