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 B
Explanation
Choice A rationale
Bleeding gums can be common during pregnancy due to increased blood flow and hormonal changes that affect the gums, causing them to be more sensitive and prone to bleeding. It's usually not a cause for immediate concern unless it's severe or accompanied by other symptoms.
Choice B rationale
Abdominal cramping at 26 weeks of gestation could indicate preterm labor or other complications, such as placental abruption. It's a significant symptom that needs immediate medical attention to ensure both maternal and fetal well-being.
Choice C rationale
White vaginal discharge, known as leukorrhea, is common during pregnancy due to increased production of estrogen and greater blood flow to the vaginal area. It helps prevent infections and usually does not indicate a problem unless it has a foul odor or is accompanied by itching or irritation.
Choice D rationale
Asymptomatic palpitations are relatively common during pregnancy due to increased blood volume and changes in circulation. They usually don't indicate a serious problem unless they're severe, persistent, or accompanied by other symptoms like chest pain or shortness of breath.
Correct Answer is C
Explanation
Choice A rationale
Starting each feeding with the same breast can lead to engorgement and decreased milk supply in the other breast.
Choice B rationale
Exclusive breastfeeding is recommended for the first six months. Providing a formula supplement can interfere with milk supply and breastfeeding success.
Choice C rationale
Allowing the newborn to empty the first breast ensures they receive hindmilk, which is richer in fat and essential for growth.
Choice D rationale
Newborns do not need additional water as breast milk or formula provides all necessary hydration.