A nurse is caring for a client who had a vaginal delivery 4 hours ago and reports perineal pain of 6 on a scale of 0 to 10. Which of the following actions should the nurse take?
Apply a corticosteroid cream to the perineal area twice daily.
Increase the client’s fluid intake for 48 hours.
Catheterize the client’s bladder.
Offer an ice pack to the client during the first 24 hours.
The Correct Answer is D
Choice A rationale
Applying a corticosteroid cream is not appropriate for acute perineal pain. It is more suitable for chronic inflammation or skin conditions.
Choice B rationale
Increasing fluid intake is beneficial for overall health, but it does not directly address acute perineal pain.
Choice C rationale
Catheterizing the bladder is not indicated for perineal pain unless there is a specific issue with urinary retention.
Choice D rationale
Offering an ice pack helps reduce swelling and numb the area, providing immediate relief for acute perineal pain. It is a standard intervention for postpartum perineal discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Taking a break and walking at least once every hour during long trips helps improve circulation and reduces the risk of blood clots, which is particularly important during pregnancy.
Choice B rationale
Wearing the shoulder harness snug across the stomach is incorrect. The shoulder harness should be worn across the chest and between the breasts to avoid pressure on the abdomen.
Choice C rationale
Positioning the lap belt across the navel is incorrect. The lap belt should be placed under the belly, across the hips and pelvic bone, to avoid pressure on the uterus.
Choice D rationale
Moving the car seat forward, close to the steering wheel, is not recommended. Pregnant women should maintain a safe distance from the steering wheel to avoid injury in case of an accident.
Correct Answer is D
Explanation
Choice A rationale
Home palliative services are typically provided for patients with terminal illnesses or those requiring end-of-life care. A molar pregnancy, while serious, does not usually necessitate palliative care. Instead, the focus is on monitoring and follow-up to ensure complete removal of molar tissue and to detect any potential complications, such as gestational trophoblastic neoplasia.
Choice B rationale
Amniocentesis is a procedure used to diagnose chromosomal abnormalities and fetal infections, typically performed during the second trimester of pregnancy. It is not relevant for a patient recovering from a molar pregnancy, as there is no viable fetus involved.
Choice C rationale
Chemotherapy may be required if there is evidence of persistent gestational trophoblastic disease or choriocarcinoma, but it is not an immediate requirement for all patients recovering from a molar pregnancy. The need for chemotherapy would be determined based on follow-up hCG levels and other diagnostic tests.
Choice D rationale
Attending a support group is an important aspect of emotional and psychological recovery after a molar pregnancy. Support groups provide a space for patients to share their experiences, receive emotional support, and gain information about their condition and recovery process.
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