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.

Answer and Explanation

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) "You should recognize that your baby sucking on his hands is a hunger cue.":
This statement is correct because babies often show early hunger cues such as sucking on their hands, rooting (turning their head towards the breast or bottle), or making sucking noises. Recognizing these early signs helps ensure that the baby is fed before they become too hungry and upset, making breastfeeding easier and more successful.

(B) "You should feed your baby for 10 minutes on each breast.":
This statement is not entirely accurate because the duration of feeding can vary widely among babies. Some babies may need more time to feed, while others may need less. It's important to allow the baby to feed until they show signs of being satisfied, such as slowing down their sucking or releasing the breast on their own.

(C) "You should feed your baby six times a day.":
Newborns typically need to be fed more frequently than six times a day, often every 2-3 hours, which can amount to 8-12 times in 24 hours. Feeding on demand, rather than following a strict schedule, ensures that the baby gets enough milk and supports the mother's milk supply.

(D) "You should wake your baby at least every 6 hours at night for feedings.":
This statement is not recommended because newborns, especially in the first few weeks, usually need to be fed more frequently than every 6 hours, even at night. It's generally advised to wake the baby for feedings every 3-4 hours if they do not wake up on their own to ensure they receive enough nutrition and maintain adequate growth and hydration

A. Serum bilirubin B. Liver enzymes C. Urinalysis for ketones D. CBC

Correct Answer is C

Explanation

(a) Serum bilirubin:
While serum bilirubin can provide useful information about liver function, it is not the most immediate concern for a client with hyperemesis gravidarum. This condition primarily involves severe nausea and vomiting, which can lead to dehydration and ketosis.

(b) Liver enzymes:
Liver enzymes can be elevated in hyperemesis gravidarum, but they are not the primary concern. The immediate priority is to assess the extent of dehydration and metabolic disturbances.

(c) Urinalysis for ketones:
This test is the priority because it helps determine the extent of dehydration and ketosis. In hyperemesis gravidarum, severe vomiting can lead to significant fluid and electrolyte imbalances and ketosis, which need to be identified and corrected promptly to prevent further complications.

(d) CBC:
A complete blood count (CBC) provides useful information about overall health and can identify anemia or infection, but it is not the priority for immediate assessment of hyperemesis gravidarum. The immediate need is to evaluate hydration status and ketosis, which is best done through urinalysis for ketones.

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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?

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