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 B
Explanation
(a) "I will need to start chemotherapy immediately."
Chemotherapy is not typically the first line of treatment for a molar pregnancy unless there is evidence of persistent gestational trophoblastic disease (GTD) or choriocarcinoma, which requires further evaluation and monitoring before making such a decision. This statement indicates a misunderstanding of the typical course of treatment after a molar pregnancy.
(b) "I will need to attend a support group when I get home."
Attending a support group can provide emotional support and coping strategies for individuals recovering from a molar pregnancy. It reflects an understanding of the importance of psychosocial support during recovery.
(c) "I will need an amniocentesis within 1 month."
Amniocentesis is not a routine follow-up procedure for a molar pregnancy. Follow-up typically includes serial measurements of hCG levels to ensure they return to normal and remain stable, which helps in monitoring for potential malignancy. This statement indicates a misunderstanding of the follow-up care required after a molar pregnancy.
(d) "I will need home palliative services after I am discharged from the hospital."
Home palliative services are generally not needed for patients recovering from a molar pregnancy, as the condition does not usually necessitate end-of-life care. This statement indicates a misunderstanding of the recovery process and the type of care required after a molar pregnancy.
Correct Answer is B
Explanation
(A) Prepare the client for an abdominal sonogram:
An abdominal sonogram is not relevant for diagnosing or treating mastitis, which is an infection of the breast tissue. Mastitis typically requires assessment of the breast and possibly a breast ultrasound if an abscess is suspected, but not an abdominal sonogram.
(B) Encourage the client to continue to breastfeed:
Continuing to breastfeed is recommended for clients with mastitis. Breastfeeding helps to drain the breast and can speed up recovery. It also helps to prevent complications such as breast abscess and supports continued milk production.
(C) Encourage the client to wear a bra that is loose fitting:
While wearing a comfortable bra is important, a loose-fitting bra may not provide the necessary support for engorged or painful breasts. A well-fitting, supportive bra is usually recommended to provide comfort without being too tight, which can exacerbate symptoms.
(D) Limit the client's daily fluid intake:
Limiting fluid intake is not recommended and is not beneficial for treating mastitis. Adequate hydration is important for overall health and helps maintain milk supply. Encouraging the client to drink plenty of fluids is essential for recovery and continued breastfeeding.
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