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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Warm compresses can help alleviate pain and inflammation associated with mastitis. The heat from the compresses increases blood flow to the affected area, promoting healing and reducing discomfort.
Choice B rationale
Wearing a nursing bra can provide support and reduce discomfort for individuals with mastitis. Avoiding a nursing bra may lead to increased pain and discomfort due to lack of support.
Choice C rationale
Limiting oral fluid intake is not recommended for individuals with mastitis. Adequate hydration is essential for overall health and can help maintain milk production, which is important for breastfeeding mothers.
Choice D rationale
Hydrocortisone ointment is not typically recommended for treating mastitis. The primary treatment for mastitis includes antibiotics, pain relief, and supportive measures such as warm compresses and continued breastfeeding.
Correct Answer is []
Explanation
Based on the provided information,
Most Likely Potential Condition
- A. Placenta previa
Actions to Take
- A. Reinforce with the client to maintain bed rest
- C. Insert a large bore intravenous catheter
Parameters to Monitor
- B. Fetal well-being
- D. Vaginal bleeding
Explanation of Other Conditions
- Abruptio placentae:
- Reasoning: This condition typically presents with painful bleeding and a tender, rigid abdomen, which is not consistent with the client’s symptoms of painless, bright red bleeding and a soft, non-tender abdomen.
- Preterm labor:
- Reasoning: The client shows no signs of labor, such as uterine contractions or cervical dilation. The bleeding is also bright red and painless, which is more indicative of placenta previa.
- Cervical insufficiency:
- Reasoning: This condition usually involves painless cervical dilation and effacement without contractions, leading to preterm birth. The client’s cervix is not dilated, and there are no signs of labor, making this condition less likely.
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