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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
(a) Acyclovir
Acyclovir is an antiviral medication used to treat herpes simplex virus infections. It is not effective against chlamydia, which is a bacterial infection, so it would not be the appropriate treatment in this case.
(b) Metronidazole
Metronidazole is an antibiotic used to treat bacterial and protozoal infections, such as bacterial vaginosis and trichomoniasis. However, it is not effective against chlamydia, so it would not be the appropriate treatment in this case.
(c) Tetracycline
Tetracycline antibiotics, including doxycycline, are effective against chlamydia infections. However, tetracyclines are contraindicated during pregnancy due to their potential to cause adverse effects on fetal bone and tooth development.
(d) Amoxicillin
Amoxicillin is a penicillin antibiotic that is safe to use during pregnancy and is effective against chlamydia infections. It is often used as an alternative treatment for chlamydia in pregnant women who cannot tolerate tetracyclines. Therefore, it is the most appropriate medication to administer in this situation.
Correct Answer is D
Explanation
(a) Pedal edema
Pedal edema, or swelling of the feet and ankles, is a common finding during pregnancy due to increased fluid retention and pressure on the lower extremities from the growing uterus. While pedal edema should be monitored, it is not typically a concerning finding unless it is severe or accompanied by other symptoms suggestive of preeclampsia.
(b) BP of 132/84 mm Hg
A blood pressure of 132/84 mm Hg is within the normal range for pregnancy. However, if the client's blood pressure continues to increase or is accompanied by other symptoms of hypertension, such as proteinuria or headaches, it may warrant further evaluation.
(c) Weight gain of 1 kg (2.2 lb)
Weight gain during pregnancy is expected and can vary from person to person and from week to week. A weight gain of 1 kg (2.2 lb) over the course of a month is within the normal range for pregnancy and may not require immediate reporting to the provider unless there are other concerning symptoms.
(d) Double vision
Double vision (diplopia) can be a symptom of several conditions, including preeclampsia, which is a serious complication of pregnancy characterized by high blood pressure and proteinuria. Double vision can also be caused by other neurological or ophthalmologic conditions. Given its potential association with preeclampsia and other serious conditions, the nurse should promptly report double vision to the provider for further evaluation and management.
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