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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. The patient has heart disease, and the antibiotics will decrease the risk to her fetus of developing endocarditis.Endocarditis is an infection of the inner lining of the heart and valves, which can be caused by bacteria entering the bloodstream during labor and delivery.Patients with mitral valve prolapse (MVP) are more prone to develop endocarditis because their valve leaflets are floppy and do not close tightly, creating a site for bacterial attachment.Antibiotics can help prevent this complication by killing the bacteria before they reach the heart.
Choice B is wrong because pericarditis is an inflammation of the outer layer of the heart, not the inner lining or valves.It is not related to MVP or bacterial infection.
Choice C is wrong because chorioamnionitis is an infection of the membranes and fluid that surround the fetus, not the heart.It is usually caused by bacteria ascending from the vagina or cervix, not from the bloodstream.
Choice D is wrong because delivering post-term does not increase the risk of systemic infection for the fetus.Systemic infection means infection that affects multiple organs or systems in the body, not just one specific site.
Correct Answer is C
Explanation
A nonstress test (NST) is a test in pregnancy that measures fetal heart rate and reaction to movement.Your pregnancy care provider performs a nonstress test to make sure the fetus is healthy and getting enough oxygen.It’s safe and painless, and gets its name because it puts no stress (nonstress) on you or the fetus.
Choice A is wrong because a nonstress test does not measure the mother’s ability to tolerate the discomfort of labor.A stress test is a different procedure that involves stimulating contractions and monitoring how the fetus responds.
Choice B is wrong because a nonstress test does not measure fetal lie, which is the position of the fetus in the uterus.
Fetal lie is usually determined by ultrasound or physical examination.
Choice D is wrong because a nonstress test does not measure maternal readiness for labor.A nonstress test typically happens after 28 weeks of pregnancy, when fetal heart rate starts reacting to movements.
Maternal readiness for labor is assessed by other factors, such as cervical dilation and effacement.
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