A nurse is caring for a client who has unrelieved episiotomy pain 8 hours following delivery.
Which of the following actions should the nurse take?

Choice A rationale:

Placing the mother in Trendelenburg's position would not correct the uterine displacement. Trendelenburg's position involves

lowering the head of the bed and raising the feet, which can actually worsen uterine displacement by increasing pressure on

the uterus from the abdominal organs.

It is not indicated for uterine displacement and could potentially have adverse effects on the patient's hemodynamic status

and respiratory function.

Choice C rationale:

Notifying the physician is important, but it is not the first action the nurse should take.

The nurse should assess the patient and attempt to correct the displacement before notifying the physician.

Choice D rationale:

Recording the findings is important for documentation, but it is not an intervention that will correct the uterine displacement.

Choice B rationale:

Massaging the fundus is the correct action to take when a postpartum uterus is displaced.

The fundus is the top of the uterus, and massaging it can help to stimulate the uterine muscles to contract and return to their

normal position.

This is often effective in correcting mild to moderate uterine displacements.

Here are the steps involved in massaging the fundus:

Locate the fundus: The nurse should first locate the fundus by palpating the abdomen just below the umbilicus.

Apply gentle pressure: Once the fundus is located, the nurse should apply gentle pressure with the fingertips in a circular

motion.

Continue massaging: The massage should be continued for several minutes, or until the uterus is felt to be firm and in the

midline position.

Additional notes:

If the uterine displacement is severe, or if the patient is experiencing pain or bleeding, the nurse should notify the physician

immediately.

Other interventions that may be used to correct uterine displacement include:

Assisting the patient to empty her bladder

Straight catheterization

Administration of oxytocin to stimulate uterine contractions

Choice A rationale:

Placing a soft pillow under the client's buttocks is not recommended for episiotomy pain relief. It can actually increase pain by

placing pressure on the perineum and reducing blood flow to the area.

Additionally, it can separate the buttocks, further straining the incision site and hindering healing.

It's crucial to prioritize interventions that promote circulation and reduce pressure on the perineum to facilitate healing and

pain management.

Choice C rationale:

Positioning a heating lamp toward the episiotomy is not appropriate within the first 24 hours following delivery.

Heat application during this early stage can increase inflammation and swelling, potentially worsening pain and delaying

healing.

It's essential to allow the initial inflammatory phase of wound healing to subside before introducing heat therapy.

Choice D rationale:

Preparing a warm sitz bath is a helpful intervention for episiotomy pain, but it's generally recommended after the first 24

hours.

During the initial phase of healing, warm water can increase blood flow to the area, potentially leading to increased swelling

and discomfort.

It's often more beneficial to focus on cooling measures within the first 24 hours to reduce inflammation and promote comfort.

Choice B rationale:

Applying an ice pack to the perineum is the most appropriate action for the nurse to take in this scenario.

Cold therapy effectively reduces inflammation, swelling, and pain by constricting blood vessels and slowing nerve conduction.

It's a non-invasive and readily available intervention that can significantly improve comfort and promote healing in the early

stages of episiotomy recovery.

Key points:

Ice packs are generally recommended for the first 24 hours following an episiotomy to reduce pain and inflammation.

Heat therapy, such as sitz baths or heating lamps, can be helpful after the initial 24-hour period to promote circulation and

healing.

Pillows or cushions under the buttocks should be avoided as they can increase pressure on the perineum and worsen pain.

Nurses play a crucial role in educating clients about episiotomy care and providing appropriate pain relief measures.