The nurse is caring for a patient that delivered 6 hours ago. She had a spontaneous vaginal delivery (SVD) with a second degree laceration that was repaired. She pushed for three hours and has swollen perineum and inflamed hemorrhoids. The patient complains of overall perineal discomfort and rates it a 6/10 on the pain scale. Which of the following interventions would the nurse include in the client’s plan of care for pain management? Select all that apply.
Warm compress.
Tucks pads.
Dermaplast spray.
Ibuprofen 600 mg PO.
Encourage the patient to sit in a high Fowler’s position.
Correct Answer : A,B,C,D
Choice A rationale
Warm compresses can help to reduce perineal pain and swelling by increasing blood flow to the area, which promotes healing and provides comfort. The warmth can also help to relax the muscles and reduce discomfort.
Choice B rationale
Tucks pads, which contain witch hazel, are effective in reducing perineal pain and swelling. Witch hazel has anti-inflammatory and astringent properties that help to soothe irritated skin and reduce swelling, providing relief from discomfort.
Choice C rationale
Dermaplast spray is a topical anesthetic that provides temporary relief from perineal pain. It contains benzocaine, which numbs the area and reduces pain. It also has antiseptic properties that help to prevent infection in the perineal area.
Choice D rationale
Ibuprofen 600 mg PO is a nonsteroidal anti-inflammatory drug (NSAID) that helps to reduce pain and inflammation. It works by inhibiting the production of prostaglandins, which are chemicals that cause inflammation and pain. Taking ibuprofen can provide significant relief from perineal discomfort.
Choice E rationale
Encouraging the patient to sit in a high Fowler’s position is not recommended for perineal pain management. This position can increase pressure on the perineum, potentially worsening the pain and discomfort.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is D
Explanation
Choice A rationale
Increasing fluid intake to 2-3 L/day is recommended to prevent dehydration and promote overall health. Adequate hydration can also help soften stools and prevent constipation.
Choice B rationale
Stool softeners are often recommended for postpartum clients, especially those with perineal trauma, to ease bowel movements and prevent straining. They help soften the stool, making it easier to pass without causing additional pain or injury.
Choice C rationale
Increasing fiber intake is beneficial for preventing constipation. High-fiber foods, such as fruits, vegetables, and whole grains, add bulk to the stool and promote regular bowel movements.
Choice D rationale
Rectal suppositories are contraindicated for clients with a fourth-degree laceration. Inserting a suppository can cause trauma to the perineal area and increase the risk of infection or further injury. Alternative methods to manage constipation should be considered.
Correct Answer is C
Explanation
Choice A rationale
Mastitis is an infection of the breast tissue that results in breast pain, swelling, warmth, and redness. It is more common in breastfeeding women and typically occurs when bacteria enter the breast tissue through a cracked or sore nipple. While it is a postpartum complication, it is not specifically associated with the delivery of twins.
Choice B rationale
Uterine infection, also known as endometritis, is an infection of the uterine lining. It can occur after childbirth, especially if there were complications such as prolonged labor, multiple vaginal exams, or manual removal of the placenta. However, it is not specifically associated with the delivery of twins.
Choice C rationale
Uterine atony is the most common cause of postpartum hemorrhage. It occurs when the uterus fails to contract effectively after childbirth, leading to excessive bleeding. The risk of uterine atony is higher in cases of overdistension of the uterus, such as with multiple gestations (twins), polyhydramnios, or a large baby. Therefore, a client who has delivered twins is at increased risk for uterine atony.
Choice D rationale
Retained placental fragments occur when parts of the placenta remain in the uterus after childbirth. This can lead to postpartum hemorrhage and infection. While it is a potential complication, it is not specifically associated with the delivery of twins.