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During the postpartum period, a hospitalized client complains of discomfort related to her episiotomy. The nurse assigns the diagnosis of 'pain related to perineal sutures.' Which nursing intervention is most appropriate during the first 24 hours following an episiotomy?
- A. Instruct the client to use petroleum jelly on the episiotomy after voiding.
- B. Encourage the client to practice Kegel exercises.
- C. Advise the client to take a warm sitz bath every four hours.
- D. Apply ice packs to the perineum.
Correct Answer: D
Rationale: The correct answer is D: Apply ice packs to the perineum. Ice packs help reduce swelling and provide numbing relief, which can help alleviate pain in the immediate postpartum period. Applying ice packs during the first 24 hours can also promote vasoconstriction, reducing the risk of bleeding and infection.
Incorrect options:
A: Using petroleum jelly can increase the risk of infection and hinder wound healing.
B: Kegel exercises are beneficial for pelvic floor strengthening but are not the most appropriate intervention for immediate pain relief.
C: While sitz baths can be soothing, they may not be suitable within the first 24 hours post-episiotomy as they can increase blood flow and potentially worsen swelling.
Overall, ice packs are the most effective and appropriate intervention for pain management in the immediate postpartum period.
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An hour after delivery, the nurse instills erythromycin (Ilotycin) ointment into the eyes of a newborn. The main objective of the treatment is to prevent infection caused by which organism?
- A. Rubella
- B. Gonorrhea
- C. Syphilis
- D. Human immunodeficiency virus (HIV)
Correct Answer: B
Rationale: The correct answer is B: Gonorrhea. Erythromycin ointment is used to prevent ophthalmia neonatorum, a purulent conjunctivitis that can result from gonorrhea infection in newborns during passage through the birth canal. Gonorrhea is a common cause of this condition, and timely administration of erythromycin helps prevent its development. Rubella, syphilis, and HIV do not typically cause ophthalmia neonatorum, so choices A, C, and D are incorrect in this context.
A nurse on a pediatric unit is assigned to care for a child with Reye syndrome. Which of the following is the most serious clinical manifestation for which the nurse should monitor?
- A. Anaphylaxis
- B. Cerebral edema
- C. Impaired coagulation
- D. Hypervolemia
Correct Answer: B
Rationale: The correct answer is B: Cerebral edema. In Reye syndrome, cerebral edema is the most serious manifestation due to increased intracranial pressure, potentially leading to brain damage or death. Anaphylaxis (A) is not typically associated with Reye syndrome. Impaired coagulation (C) can occur but is not as immediately life-threatening as cerebral edema. Hypervolemia (D) is a possible complication but not as critical as cerebral edema in Reye syndrome.
A nurse is reinforcing teaching to a group of parents about preventing accidental poisoning in preschoolers.
- A. "Have syrup of ipecac available in the home."'
- B. "Explain to preschool children that plants can be eaten only after they are cooked."'
- C. "Keep labels on containers of toxic substances and never remove them."'
- D. "Place medications in a cabinet above the sink."'
Correct Answer: C
Rationale: The correct answer is C. Keeping labels on containers of toxic substances is crucial as it provides important information about the contents and hazards. Removing labels can lead to confusion and accidental ingestion. Syrup of ipecac (choice A) is no longer recommended for poisoning treatment. Teaching children to eat cooked plants (choice B) does not address the issue of accidental poisoning. Placing medications above the sink (choice D) may still be accessible to preschoolers.
A nurse is preparing to administer an intramuscular (IM) injection to a 2-month-old infant. Which of the following is the preferred injection site?
- A. "Vastus lateralis"'
- B. "Deltoid muscle"'
- C. "Ventrogluteal site"'
- D. NA
Correct Answer: A
Rationale: The correct answer is A: "Vastus lateralis." For infants, the vastus lateralis muscle in the thigh is the preferred site for IM injections due to its large size, well-developed muscle mass, and minimal major blood vessels and nerves. This reduces the risk of injury and ensures proper medication absorption. The deltoid muscle (choice B) is typically used for older children and adults, not infants. The ventrogluteal site (choice C) is more commonly used for adults and older children as well. Not Applicable (choice D) does not provide any relevant information.
A nurse is caring for a child with muscular dystrophy. Which of the following priority actions should the nurse include in the care of this child?
- A. Limit physical activity and plan frequent rest periods to avoid overexertion and exhaustion of muscle groups.
- B. Recommend genetic counseling for parents,male siblings and paternal uncles and their male offspring.
- C. Advise against flu and pneumococcal vaccines due to a compromised respiratory system.
- D. Have the child use an incentive spirometer and perform breathing exercises routinely.
Correct Answer: D
Rationale: The correct answer is D: Have the child use an incentive spirometer and perform breathing exercises routinely. This is the priority action because children with muscular dystrophy are at risk for respiratory complications due to weakened respiratory muscles. Using an incentive spirometer and performing breathing exercises help maintain lung function and prevent respiratory infections.
A: Limiting physical activity and planning rest periods is important, but respiratory care takes precedence in muscular dystrophy.
B: Genetic counseling is important for family planning but does not directly impact the child's care.
C: Advising against vaccines can increase the risk of infections in a child with compromised respiratory function.
E, F, G: No information provided.