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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
(A) "A Papanicolaou test will be performed to detect the presence of herpes simplex type 1."
The Papanicolaou (Pap) test is not performed during pregnancy to detect herpes simplex type 1. The Pap test is a cervical cancer screening test that detects abnormal cervical cells, usually caused by human papillomavirus (HPV) infection or other factors. It is not used to detect herpes simplex type 1.
(B) "A group B streptococcus screening will be performed to determine the presence of STs."
Group B Streptococcus (GBS) screening is performed during pregnancy to detect the presence of GBS bacteria in the mother's genital and rectal areas. GBS is a common bacteria that can cause serious infections in newborns if passed from the mother during childbirth. GBS screening is not related to sexually transmitted infections (STIs).
(C) "A multiple marker screening will be performed to identify neural tube defects."
Multiple marker screening, also known as maternal serum screening or quad screen, is a routine prenatal test performed between 15 and 20 weeks of gestation. It helps identify the risk of certain chromosomal abnormalities, including neural tube defects like spina bifida and anencephaly. This screening measures the levels of certain proteins in the mother's blood to assess the risk of these birth defects.
(D) "A glucose tolerance test will be performed to predict hyperglycemia in your baby."
A glucose tolerance test (GTT) is performed during pregnancy to diagnose gestational diabetes mellitus (GDM), a condition characterized by high blood sugar levels during pregnancy. The purpose of the GTT is to identify maternal hyperglycemia, which can lead to complications for both the mother and the baby. The test is not performed to predict hyperglycemia specifically in the baby.
Correct Answer is B
Explanation
Answer: B. Determine the newborn's respiratory rate.
Rationale:
A. Weigh the newborn's wet diaper:
While monitoring fluid output is important in assessing hydration status and overall health, it is not the immediate priority. In the context of a newborn with neonatal abstinence syndrome (NAS), the respiratory status takes precedence, especially given that withdrawal can affect respiratory function.
B. Determine the newborn's respiratory rate:
Assessing the respiratory rate is crucial, as newborns with NAS may experience respiratory distress, including increased respiratory effort or apnea. Identifying any respiratory issues early allows for prompt intervention, which is vital for the newborn's safety and well-being. Ensuring adequate respiratory function is a priority in this population.
C. Auscultate the newborn's bowel sounds:
While assessing bowel sounds is relevant to monitoring gastrointestinal function and potential withdrawal symptoms, it is not the immediate priority. Changes in bowel sounds may occur due to the syndrome, but respiratory assessment should come first to ensure stability.
D. Swaddle the newborn in blankets:
Swaddling can provide comfort to a newborn with NAS; however, it is not the first action to take. Comfort measures are important, but they should follow critical assessments of the newborn's respiratory and overall clinical status to ensure safety.
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