A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse recognizes this finding as an indication of which of the following conditions?

Choice A rationale:

The nurse should report the blood pressure findings to the provider because there is a significant increase in both systolic and diastolic blood pressure. At 0900, the blood pressure was 156/90 mm Hg, and at 1000, it increased to 160/96 mm Hg. This significant elevation in blood pressure can be a cause for concern as it may indicate the development of gestational hypertension or preeclampsia, which can be dangerous for both the client and the fetus.

Choice B rationale:

Cerebral manifestations are not mentioned in the nurse's notes or vital signs and are not relevant to the given scenario. Therefore, this choice is not applicable in this case.

Choice C rationale:

The nurse should report the fetal heart rate findings to the provider because it is not included in the vital signs section of the nurse's notes. Monitoring the fetal heart rate is essential to ensure the well-being of the fetus, and any abnormalities or changes in the fetal heart rate should be promptly reported to the healthcare provider for further evaluation.

Choice D rationale:

The nurse should report the respiratory rate findings to the provider. Although the respiratory rate seems to be within the normal range (22/min at 0900 and 21/min at 1000), it is a vital sign that should be closely monitored in pregnant clients. Any sudden changes or abnormalities in the respiratory rate may indicate respiratory distress or other health issues that need medical attention. Choices E and F rationale: Deep tendon reflexes and gastrointestinal assessment findings are not mentioned in the nurse's notes or vital signs. These options are not applicable in this scenario and do not require reporting to the provider.

The correct answer is choice B: Apply an ice pack to the perineum. This is the recommended action for unrelieved episiotomy pain within the first 24 hours following delivery, as it helps reduce swelling and provide pain relief.

Choice A rationale:

Placing a soft pillow under the client’s buttocks may provide comfort, but it does not directly address the inflammation and pain associated with an episiotomy. It is not the primary intervention for unrelieved episiotomy pain shortly after delivery.

Choice B rationale:

Applying an ice pack to the perineum is a standard practice for reducing pain and swelling after an episiotomy. The cold temperature causes vasoconstriction, which can help to decrease swelling and provide pain relief. This is especially effective within the first 24 hours post-delivery.

Choice C rationale:

Positioning a heating lamp toward the episiotomy is not recommended immediately following the procedure, as heat can increase blood flow to the area, potentially worsening swelling and pain in the acute phase after the surgery.

Choice D rationale:

While a warm sitz bath may be beneficial for episiotomy pain relief, it is typically recommended after the initial 24-hour period post-delivery. In the first 24 hours, cold therapy is preferred to reduce acute inflammation and pain.