A nurse is caring for a client who had a vaginal delivery 4 hr ago and reports perineal pain of 6 on a scale of 0 to 10. Which of the following actions should the nurse take?
Offer an ice pack to the client during the first 24 hr.
Apply a corticosteroid cream to the perineal area twice daily.
Increase the client's fluid intake for 48 hr.
Catheterize the client's bladder.
The Correct Answer is A
(a) Offer an ice pack to the client during the first 24 hr.
Offering an ice pack is an appropriate intervention for managing perineal pain and swelling in the immediate postpartum period. Ice helps to reduce inflammation and numb the area, providing pain relief. This is a standard recommendation for managing perineal pain after vaginal delivery.
(b) Apply a corticosteroid cream to the perineal area twice daily.
Applying a corticosteroid cream is not typically recommended for perineal pain immediately after delivery. These creams are generally used for inflammatory skin conditions and not for the acute management of perineal pain and swelling after childbirth.
(c) Increase the client's fluid intake for 48 hr.
While maintaining adequate hydration is important for overall recovery, increasing fluid intake specifically does not address the client's perineal pain. This intervention would not provide immediate pain relief for the perineal area.
(d) Catheterize the client's bladder.
Catheterizing the bladder is not a standard intervention for perineal pain. It is typically done if the client has urinary retention or difficulty voiding, not for managing pain. This action would not directly alleviate the perineal pain the client is experiencing.
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Related Questions
Correct Answer is D
Explanation
(A) Ask a parent to state the newborn's date of birth:
While asking a parent to state the newborn's date of birth may seem like a reasonable step, it relies on the parent's memory and verbal confirmation, which may not always be accurate. It's possible for a parent to forget or provide incorrect information, leading to potential identification errors.
(B) Check the newborn's footprint sheet with the medical record:
Footprint identification is a common practice in hospitals, but it may not always be feasible or practical during routine newborn transport to parents. Additionally, relying solely on footprints for identification may not be as reliable as comparing identification bands, as footprints can smudge or be difficult to match accurately.
(C) Request a parent to verify the newborn's name:
Asking a parent to verify the newborn's name relies on verbal confirmation, similar to option A. While it may provide some level of reassurance, it is not as reliable as comparing identification bands to confirm identity. Additionally, newborns may not yet have been formally named at the time of transport.
(D) Compare numbers on the newborn's band to the parent's band:
Comparing the identification numbers on the newborn's identification band with those on the parent's identification band is the most reliable method to confirm the newborn's identity. This process ensures that the newborn is matched with the correct parent(s) before handing over the infant. It helps prevent instances of newborn mix-up or abduction.
Correct Answer is A
Explanation
(A) Perform fundal massage:
Performing fundal massage is the highest priority action in this scenario. Complete saturation of the perineal pad within 30 minutes postpartum suggests excessive bleeding, which could indicate postpartum hemorrhage (PPH). Fundal massage helps to stimulate uterine contractions, which can aid in controlling bleeding by compressing blood vessels at the placental site. It is essential to assess the fundus for firmness and position and massage it if necessary, to prevent or manage PPH.
(B) Weigh the perineal pad:
Weighing the perineal pad can provide information about the amount of blood loss, but it is not the highest priority action at this moment. Fundal massage takes precedence to address the potential underlying cause of excessive bleeding.
(C) Apply oxygen by face mask:
While oxygen therapy may be indicated in certain situations, such as respiratory distress, it is not the highest priority in this scenario. The priority is to address the potential cause of excessive bleeding and prevent further complications associated with postpartum hemorrhage.
(D) Monitor urine output:
Monitoring urine output is an important aspect of postpartum care, but it is not the highest priority when the client is experiencing excessive bleeding. Addressing the potential cause of bleeding and preventing complications associated with postpartum hemorrhage take precedence.
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