A nurse is caring for a client who had a vaginal delivery 4 hours ago and reports perineal pain of 6 on a scale of 0 to 10. Which of the following actions should the nurse take?

Apply a corticosteroid cream to the perineal area twice daily.

Increase the client’s fluid intake for 48 hours.

Catheterize the client’s bladder.

Offer an ice pack to the client during the first 24 hours.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Applying a corticosteroid cream is not appropriate for acute perineal pain. It is more suitable for chronic inflammation or skin conditions.

Choice B rationale

Increasing fluid intake is beneficial for overall health, but it does not directly address acute perineal pain.

Choice C rationale

Catheterizing the bladder is not indicated for perineal pain unless there is a specific issue with urinary retention.

Choice D rationale

Offering an ice pack helps reduce swelling and numb the area, providing immediate relief for acute perineal pain. It is a standard intervention for postpartum perineal discomfort.

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Correct Answer is C

Explanation

Choice A rationale

Verifying that the newborn is Rh-negative is not necessary for administering Rh(D) immune globulin. The medication is given to Rh-negative mothers to prevent Rh sensitization, regardless of the newborn’s Rh status.

Choice B rationale

A positive Coombs test indicates that the mother has already been sensitized to Rh-positive blood cells, making Rh(D) immune globulin ineffective in preventing sensitization.

Choice C rationale

Administering Rh(D) immune globulin within 72 hours after birth is crucial to prevent Rh sensitization in future pregnancies. This timing ensures that the mother’s immune system does not produce antibodies against Rh-positive blood cells.

Choice D rationale

Rh(D) immune globulin is typically administered intramuscularly, not into the abdomen. The preferred sites are the deltoid muscle or the anterolateral aspect of the thigh.

A. Avocados. B. Peanut butter. C. Yogurt. D. Long grain rice.

Correct Answer is C

Explanation

Choice A rationale

Avocados are a good source of healthy fats, vitamins, and minerals, but they are not particularly high in calcium. They are beneficial for overall health but not specifically for increasing calcium intake.

Choice B rationale

Peanut butter is a good source of protein and healthy fats, but it is not a significant source of calcium. It can be part of a balanced diet but will not substantially increase calcium levels.

Choice C rationale

Yogurt is an excellent source of calcium, which is essential for bone health, especially during pregnancy. It also provides probiotics, which can aid in digestion and overall health.

Choice D rationale

Long grain rice is a good source of carbohydrates and some vitamins, but it is not high in calcium. It can be part of a balanced diet but will not significantly contribute to calcium intake.

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A nurse is caring for a client who had a vaginal delivery 4 hours ago and reports perineal pain of 6 on a scale of 0 to 10. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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