Author Question: The nurse is planning comfort measures to implement for a client after a vaginal birth. Which ... (Read 65 times)

Kthamas · **on:** Jun 28, 2018

The nurse is planning comfort measures to implement for a client after a vaginal birth. Which measures should the nurse plan to implement? (Select all that apply.)

a. Sitz baths four times a day
b. Use of only warm water with the sitz baths
c. Topical anesthetic spray after perineal care
d. Ice pack to the perineum for the first 24 hours
e. Sitting while relaxing the perineal and buttock areas

Question 2

The nurse is teaching a client with a midline episiotomy about perineal care after a vaginal birth. Which statements by the client indicate she understands the teaching? (Select all that apply.)

a. I will gently pat the perineum dry rather than wipe.
b. I will only use the perineal bottle after bowel movements.
c. I will use cold water in the perineal bottle as I cleanse.
d. I will use the perineal bottle without touching the perineum.

cdmart10 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: A, C, D
Sitz baths provide continuous circulation of water, cleansing and comforting the traumatized perineum. Ice causes vasoconstriction and is most effective if applied soon after the birth to prevent edema and to numb the area. Anesthetic sprays decrease surface discomfort and allow more comfortable ambulation. Cool water in the sitz bath reduces pain caused by edema and may be most effective within the first 24 hours. The mother should be advised to squeeze her buttocks together, not relax them, before sitting, and to lower her weight slowly onto her buttocks.

Answer to Question 2

ANS: A, D
The bottle should not touch the perineum. The perineum is gently patted rather than wiped dry. Perineal care consists of squirting warm water over the perineum after each voiding or bowel movement. Therefore, cold water should not be used; perineal care should be performed after voiding and after bowel movements.