A nurse is caring for a client who is postpartum and has an episiotomy. Which of the following actions should the nurse take?
Instruct the client to apply anesthetic spray to the site three to four times a day.
Encourage the client to change perineal pads at least three times a day.
Assist the client to fill the squeeze bottle with cold water to perform perineal care.
Alternate warm and ice packs to the site every 2 hours for the first 24 hours postpartum.
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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Correct Answer is A
Explanation
Choice A rationale
"Decreased BP.”. This is correct because hyperemesis gravidarum can lead to dehydration, which in turn can cause hypotension (decreased blood pressure).
Choice B rationale
"WBC count 15,000/mm³ (5,000 to 15,000/mm³).”. This is incorrect because while WBC count can be elevated due to stress or infection, it is not a primary manifestation of hyperemesis gravidarum.
Choice C rationale
"Pruritus.”. This is incorrect because pruritus is not commonly associated with hyperemesis gravidarum. It is more likely related to other conditions like cholestasis of pregnancy.
Choice D rationale
"Hemoglobin 18 g/dL (11 to 16 g/dL).”. This is incorrect because an elevated hemoglobin level is not a direct manifestation of hyperemesis gravidarum, although dehydration can potentially concentrate blood components and slightly elevate hemoglobin.
Correct Answer is D
Explanation
Choice A rationale
Leukorrhea, a normal vaginal discharge, increases during pregnancy due to hormonal changes. It's not indicative of prenatal complications at 41 weeks of gestation.
Choice B rationale
Shortness of breath is common in late pregnancy due to the enlarged uterus pressing against the diaphragm. It is not necessarily a sign of a prenatal complication at this stage.
Choice C rationale
Non-pitting ankle edema is often seen in late pregnancy due to fluid retention and increased pressure on the veins. It is typically benign and not a sign of serious complications.
Choice D rationale
Blurred vision can indicate a serious prenatal complication such as preeclampsia, which is characterized by high blood pressure and can pose significant risks to both mother and baby if not managed properly. .