While the RN is assessing a mother’s perineum on her 2nd postpartum day after having a vaginal delivery, the RN notes a large ecchymotic area located to the left of the mother’s perineum.
Which one of the following interventions should the RN initiate at this time?
A . Have the client expose the area to air.
B . Apply ice to the perineum.
C . Encourage the client to take warm sitz baths.
D . Inform the physician.
Answer: C
Explanation:
(A) The area is bruised and painful. This action would do nothing to help with the healing process of the perineum or to provide comfort.
(B) Ice is effective immediately after birth to reduce edema and discomfort, but not on the 2nd postpartum day.
(C) Sitz baths are useful if the perineum has been traumatized, because the moist heat increases circulation to the area to promote healing, relaxes tissue, and decreases edema.
(D) The physician is not notified of bruising, but if a hematoma is present, then the physician is notified.
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