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) "White blood cell count is an indicator of anemia.”
White blood cell count is not directly related to anemia. Anemia is typically assessed by hemoglobin and hematocrit levels, which reflect the oxygen-carrying capacity of the blood. White blood cell count measures immune system function and can indicate infection or inflammation rather than anemia.
(B) "Urine specific gravity identifies my risk for pregnancy induced hypertension.”
Urine specific gravity is a measure of urine concentration and hydration status, and it is not typically used to identify the risk of pregnancy-induced hypertension (preeclampsia). Preeclampsia is diagnosed based on symptoms such as hypertension (high blood pressure) and proteinuria (protein in the urine), along with other criteria.
(C) "Platelet count identifies if I am at risk for bleeding.”
Platelet count is a laboratory test that measures the number of platelets in the blood. Platelets are essential for blood clotting, so a low platelet count (thrombocytopenia) can indicate an increased risk of bleeding, which is pertinent to pregnancy, especially in cases of conditions like gestational thrombocytopenia or preeclampsia.
(D) "Sedimentation rate checks for signs of cancer.”
The sedimentation rate (ESR or sed rate) is a nonspecific test that measures inflammation in the body, but it is not used to check for signs of cancer specifically. Elevated sedimentation rate can indicate various inflammatory conditions such as infection, autoimmune diseases, or chronic inflammatory disorders. It is not a primary test for cancer diagnosis.
Correct Answer is A
Explanation
(a) Supine
Placing the newborn in the supine position (on their back) for sleep is recommended by pediatric guidelines to reduce the risk of sudden infant death syndrome (SIDS) and other sleep-related causes of infant death. The supine position allows for optimal airway patency and decreases the risk of suffocation. This position is safest for the newborn during sleep.
(b) Prone
Placing the newborn in the prone position (on their stomach) for sleep is not recommended due to an increased risk of SIDS. The prone position can obstruct the infant's airway and increase the risk of suffocation or overheating, leading to adverse outcomes.
(c) Left lateral
While placing the newborn on the left side may be recommended for certain medical procedures or interventions, such as feeding to reduce reflux, it is not recommended for sleep positioning. Placing the newborn in the left lateral position during sleep does not provide the same benefits for airway patency and SIDS risk reduction as the supine position.
(d) Right lateral
Similar to the left lateral position, placing the newborn on the right-side during sleep does not offer the same protective benefits as the supine position. It does not reduce the risk of SIDS and may pose similar risks as the prone position, such as airway obstruction.
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