A postpartum client who delivered vaginally 6-hours ago and had a second-degree perineal laceration reports feeling increased pain and pressure in her vaginal area. Which intervention should the practical nurse (PN) implement?
Notify the healthcare provider.
Provide routine perineal care.
Medicate with 800 mg ibuprofen.
Apply an icepack to the perineum.
The Correct Answer is D
If a postpartum client who delivered vaginally 6-hours ago and had a second-degree perineal laceration reports feeling increased pain and pressure in her vaginal area, the practical nurse (PN) should apply an icepack to the perineum.Applying an icepack can help reduce swelling and provide pain relief in the affected area. The PN should also monitor the client's condition and report any changes or concerns to the healthcare provider. The other interventions listed may also be appropriate in some situations, but applying an icepack to the perineum is the most appropriate initial intervention in this situation.
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Correct Answer is B
Explanation
Based on the assessment findings, the infant is at the greatest risk for developing anemia due to a lack of iron. Infants should begin eating solid foods that are rich in iron at around 6 months of age to ensure they are getting enough of this important nutrient. Drinking whole milk from a bottle can displace other foods that are rich in iron and contribute to the development of anemia.
Option A, allergies related to whole milk, is a possibility but not the greatest risk in this situation.
Option C, obesity due to increased calorie count, is also a possibility but not the greatest risk.
Option D, lactose intolerance due to whole milk, is a possibility but not the greatest risk in this situation.
Correct Answer is C
Explanation
Restlessness, confusion, and agitation are common symptoms of dementia, particularly in the evening, a phenomenon known as sundowning. Therefore, the PN should implement interventions that can help to prevent or minimize these symptoms. Assigning the client to a room close to the nurses' station can help to provide constant observation and reassurance and can help to prevent the client from wandering or becoming disoriented.
A. Delaying administration of nighttime medications until after visitors have left may be appropriate, but it is not the first intervention to be implemented in this scenario.
B. Administering a prescribed PRN benzodiazepine at the onset of a confused state may be appropriate in some cases, but it should not be the first intervention to be implemented in this scenario.
D. Asking family members about how they dealt with the client in the evening may be helpful, but it is not the first intervention to be implemented in this scenario.
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