The nurse is teaching a client with a midline episiotomy about perineal care after vaginal birth. Which statement from the client indicates she

Correct Answer: C

Rationale: This statement indicates a correct understanding of perineal care after a midline episiotomy. After vaginal birth, it is important to avoid wiping the perineal area to prevent irritation and infection. Instead, gently patting the area dry is recommended to promote healing and prevent discomfort. This approach helps to minimize trauma to the sensitive tissues of the perineum and reduces the risk of introducing bacteria from wiping.

Correct Answer: A

Rationale: When a patient receives an epidural anesthesia during the first stage of labor, it can lead to temporary bladder dysfunction. The epidural can affect the patient's ability to feel the sensation of a full bladder and may impair the ability to voluntarily urinate. If the epidural is discontinued immediately after delivery during the fourth stage of labor, the patient may be at an increased risk of bladder distention due to the residual effects of the epidural. Therefore, monitoring for bladder distention and ensuring adequate bladder emptying is important to prevent complications.

Correct Answer: A

Rationale: The correct first action when a delivering patient's water breaks is to check the fetal heart tone. This is important to assess the well-being of the baby and ensure there are no signs of distress. Once the fetal heart tone is confirmed, the nurse can proceed with notifying the physician, changing bed linen, and encouraging the mother to go for a walk as needed. But the priority should always be to assess the fetal well-being in such a situation.

Correct Answer: A

Rationale: The most important nursing action to undertake at this time is obtaining a fetal heart rate (FHR) assessment. Monitoring the FHR is crucial during labor to assess the well-being of the baby and detect any signs of fetal distress. This information helps guide the healthcare team in determining the appropriate course of action to ensure the safety of both the mother and baby. It takes precedence over other tasks such as completing a sterile vaginal exam, assessing the odor of amniotic fluid, performing Leopold's maneuver, or obtaining pain medication orders. Monitoring the FHR should be the immediate priority in this situation.

Correct Answer: A

Rationale: In the context of newborn care, understanding the modes of heat loss in infants is crucial for maintaining their thermoregulation and preventing complications. Radiation is the transfer of heat from the baby to a cooler surface without direct contact. This mode of heat loss is significant in newborns due to their large body surface area to mass ratio. Conduction involves the transfer of heat from the baby to a cooler surface through direct contact. This can occur when placing the baby on a cold surface without adequate insulation. Convection is the loss of heat from the baby to the surrounding air. Air movement can enhance this process, leading to increased heat loss. Perspiration, as mentioned in option D, is not a significant mode of heat loss in newborns. Newborns have immature sweat glands and do not sweat effectively for thermoregulation. Educationally, understanding these modes of heat loss is essential for healthcare providers working with newborns to implement appropriate interventions to maintain their body temperature within a normal range, which is crucial for their overall well-being.