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 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.
Correct Answer is C
Explanation
(a) "White blood cell count is an indicator of anemia."
A white blood cell (WBC) count is primarily used to assess for infection or inflammation, not anemia. Anemia is typically evaluated by measuring hemoglobin and hematocrit levels, not WBC count. This statement indicates a misunderstanding of the purpose of the WBC count.
(b) "Urine specific gravity identifies my risk for pregnancy induced hypertension."
Urine specific gravity measures the concentration of urine and is used to assess hydration status and kidney function. It does not directly identify the risk for pregnancy-induced hypertension (PIH). The presence of protein in the urine (proteinuria) would be more indicative of PIH. This statement indicates a misunderstanding of the purpose of the urine specific gravity test.
(c) "Platelet count identifies if I am at risk for bleeding."
This is the correct statement. A platelet count is used to determine the number of platelets in the blood, which are essential for normal blood clotting. A low platelet count (thrombocytopenia) can indicate an increased risk of bleeding, while a high count (thrombocytosis) can be associated with clotting disorders.
(d) "Sedimentation rate checks for signs of cancer."
The erythrocyte sedimentation rate (ESR) measures how quickly red blood cells settle at the bottom of a test tube. It is a nonspecific test used to detect inflammation in the body. While an elevated ESR can be associated with various conditions, including infections, autoimmune diseases, and cancers, it is not specifically used to check for cancer. This statement indicates a misunderstanding of the purpose of the sedimentation rate test.
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