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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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.
Correct Answer is D
Explanation
(a) "I should place my baby in the car seat at a 90-degree angle."
The baby should not be placed in the car seat at a 90-degree angle. Instead, the car seat should be reclined at a 30- to 45-degree angle to keep the baby's airway open and reduce the risk of suffocation.
(b) "I will place a thick, soft pad behind my baby's back."
Using a thick, soft pad behind the baby’s back is not recommended because it can interfere with the harness system and compromise the safety of the car seat. Only products that come with the car seat or are specifically designed for it should be used.
(c) "I can turn the car seat so it faces forward when my baby weighs 15 pounds."
The car seat should remain rear-facing until the child reaches the maximum weight or height limit allowed by the car seat manufacturer, which is typically around 2 years of age or longer. Turning the car seat to face forward at just 15 pounds is too early and not safe.
(d) "I will place the retainer clip at the level of my baby's armpits."
This is correct. The retainer clip should be positioned at the level of the baby's armpits. This placement ensures that the harness straps are properly positioned over the baby's shoulders and chest, providing optimal protection in the event of a crash.
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