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A nurse is caring for a client who is postpartum and has an episiotomy. Which of the following actions should the nurse take?

A.

Instruct the client to apply anesthetic spray to the site three to four times a day.

B.

Encourage the client to change perineal pads at least three times a day.

C.

Assist the client to fill the squeeze bottle with cold water to perform perineal care.

D.

Alternate warm and ice packs to the site every 2 hours for the first 24 hours postpartum.

Answer and Explanation

The Correct Answer is D

Choice A rationale

 

Instructing the client to apply anesthetic spray to the site three to four times a day is incorrect. While anesthetic sprays can help with pain relief, it's more important to manage swelling and discomfort with a combination of methods, including ice packs and perineal care.

 

Choice B rationale

 

Encouraging the client to change perineal pads at least three times a day is insufficient. Pads should be changed more frequently to maintain hygiene and prevent infection.

 

Choice C rationale

 

Assisting the client to fill the squeeze bottle with cold water to perform perineal care is incorrect. While perineal care is important, cold water is not typically recommended as it may not provide comfort and might even cause discomfort.

 

Choice D rationale

 

Alternating warm and ice packs to the site every 2 hours for the first 24 hours postpartum is correct. This method helps manage pain and swelling effectively, promoting healing and comfort for the client.

 


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View Related questions

Correct Answer is B

Explanation

Choice A rationale

Elevating the client's legs is incorrect as an initial intervention. It is more important to address the potential cause of the late decelerations first.

Choice B rationale

Turning the client onto their side is correct. This intervention can improve blood flow to the fetus and reduce the pressure on the vena cava, potentially alleviating late decelerations.

Choice C rationale

Palpating the client's uterus is not the first action. It is essential to address maternal positioning and oxygenation issues first.

Choice D rationale

Increasing the client's IV fluid infusion rate may help, but it is not the initial action. Positioning changes can have an immediate effect on fetal oxygenation.

Correct Answer is A

Explanation

Choice A rationale

Positioning the newborn's car seat at a 45° angle helps to maintain an open airway and reduces the risk of the baby's head falling forward, which can obstruct breathing.

Choice B rationale

Placing the car seat in a forward-facing position is incorrect for a newborn. Newborns and infants should always be placed in a rear-facing car seat to protect their head, neck, and spine in the event of a crash.

Choice C rationale

Placing a rolled blanket behind the newborn's neck is not recommended as it can alter the position of the head and neck, potentially compromising the airway. Proper positioning is crucial to ensure safety and comfort.

Choice D rationale

The retainer clip should be positioned at the level of the newborn's armpits, not the umbilicus. Proper placement of the retainer clip ensures that the harness is secure and reduces the risk of injury in a collision.

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