The patient is recovering from a delivery that included a midline ...

[Marty]

The patient is recovering from a delivery that included a midline episiotomy. Her perineum is swollen and sore. Ten minutes after an ice pack is applied, the patient asks for another. The best response from the nurse is:
 
  1. I'll get you one right away.
  2. You only need to use one ice pack.
  3. You need to leave it off for at least 20 minutes and then reapply.
  4. I'll bring you an extra so that you can change it when you are ready.

Question 2

The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant's gestational age is 33 weeks based on early ultrasound and last menstrual period.
 
  The nurse expects the infant to exhibit which of the following? 1. Full sole creases, nails extending beyond the fingertips, scarf sign showing the elbow beyond the midline
  2. Testes located in the upper scrotum, rugae covering the scrotum, vernix covering the entire body
  3. Ear cartilage folded over, lanugo present over much of the body, slow recoil time
  4. 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension

[Jbrasil]

Answer to Question 1

3
Rationale 1: Providing an additional ice pack before 20 minutes have passed would increase the perineal edema.
Rationale 2: More than one ice pack must be used in order to apply ice for 20 minutes on followed by 20 minutes off.
Rationale 3: Optimal effects from the use of an ice pack occur when it is applied for 2030 minutes and then removed for at least 20 minutes before being reapplied.
Rationale 4: An ice pack that is provided now for use in 20 minutes would melt before being used.

Answer to Question 2

3
Explanation: 3. Ear cartilage folded over, lanugo present over much of the body, and slow recoil time are all characteristics of a preterm infant.