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.

Answer and Explanation

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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Correct Answer is C

Explanation

(a) Touch the corner of the newborn's mouth:
Touching the corner of the newborn's mouth elicits the rooting reflex, not the Babinski reflex. The rooting reflex causes the newborn to turn their head toward the touch and open their mouth, which helps with feeding.

(b) Place the newborn supine and apply pressure to the soles of the feet:
Applying pressure to the soles of the feet is not a method used to elicit the Babinski reflex. This action might influence other reflexes but not the Babinski.

(c) Stroke upward on the lateral aspect of the sole of the newborn's foot:
This is correct. The Babinski reflex is elicited by stroking upward on the lateral aspect of the sole of the newborn's foot. A positive response is the fanning and extension of the toes, which is normal in newborns.

(d) Pull the newborn up by the wrist from a supine position:
Pulling the newborn up by the wrists from a supine position is used to assess the traction response or pull-to-sit maneuver, which tests the newborn's head control and muscle tone, not the Babinski reflex.

A. "A Papanicolaou test will be performed to detect the presence of herpes simplex type 1." B. "A group B streptococcus screening will be performed to determine the presence of STs." C. "A multiple marker screening will be performed to identify neural tube defects." D. "A glucose tolerance test will be performed to predict hyperglycemia in your baby"

Correct Answer is C

Explanation

(A) "A Papanicolaou test will be performed to detect the presence of herpes simplex type 1."
The Papanicolaou (Pap) test is not performed during pregnancy to detect herpes simplex type 1. The Pap test is a cervical cancer screening test that detects abnormal cervical cells, usually caused by human papillomavirus (HPV) infection or other factors. It is not used to detect herpes simplex type 1.

(B) "A group B streptococcus screening will be performed to determine the presence of STs."
Group B Streptococcus (GBS) screening is performed during pregnancy to detect the presence of GBS bacteria in the mother's genital and rectal areas. GBS is a common bacteria that can cause serious infections in newborns if passed from the mother during childbirth. GBS screening is not related to sexually transmitted infections (STIs).

(C) "A multiple marker screening will be performed to identify neural tube defects."
Multiple marker screening, also known as maternal serum screening or quad screen, is a routine prenatal test performed between 15 and 20 weeks of gestation. It helps identify the risk of certain chromosomal abnormalities, including neural tube defects like spina bifida and anencephaly. This screening measures the levels of certain proteins in the mother's blood to assess the risk of these birth defects.

(D) "A glucose tolerance test will be performed to predict hyperglycemia in your baby."
A glucose tolerance test (GTT) is performed during pregnancy to diagnose gestational diabetes mellitus (GDM), a condition characterized by high blood sugar levels during pregnancy. The purpose of the GTT is to identify maternal hyperglycemia, which can lead to complications for both the mother and the baby. The test is not performed to predict hyperglycemia specifically in the baby.

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