Health Promotion and Maintenance
11. A client delivered a 7-pound, 6-ounce neonate 14 hours ago over a midline episiotomy. Upon assessment, a nurse notes that the client has perineal pain of 7/10 on a numeric scale. Which actions should the nurse take? Select all that apply.
. Perform perineal hygiene after voiding.
. Encourage adequate fluid intake.
. Apply an ice pack to her perineum.
. Suggest taking a sitz bath several times a day.
. Provide topical anesthetics as ordered by the physician.
Test-Taking Tip
The key concept in this question is the treatment and prevention of perineal pain related to the delivery. Choose the interventions that decrease pain.
Content Area: Maternity, Postpartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Health Promotion and Maintenance
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Answer 1 is incorrect because, although perineal hygiene can decrease the chance for infection, perineal hygiene after voiding will not be helpful in decreasing her perineal pain. Using the peri bottle during urination can decrease the pain caused by urination. Answer 2 is correct because staying well hydrated by drinking plenty of water can be helpful in decreasing pain caused by constipation. Straining with bowel movements will stretch the episiotomy scar and perineum and can cause pain. Avoid constipation by eating fiber-rich foods such as fresh fruits and vegetables. Answer 3 is correct because applying an ice pack is helpful in decreasing perineal pain by decreasing perineal edema. Answer 4 is correct because taking a sitz bath several times a day can decrease the pain by increasing the circulation to the perineum. Answer 5 is correct because topical anesthetics, as ordered by the physician, can decrease the perineal pain by slowing down the rate at which pain sensors in the skin send pain messages to the brain, and by reducing perineal swelling.