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 B
Explanation
(A) Prepare the client for an abdominal sonogram:
An abdominal sonogram is not relevant for diagnosing or treating mastitis, which is an infection of the breast tissue. Mastitis typically requires assessment of the breast and possibly a breast ultrasound if an abscess is suspected, but not an abdominal sonogram.
(B) Encourage the client to continue to breastfeed:
Continuing to breastfeed is recommended for clients with mastitis. Breastfeeding helps to drain the breast and can speed up recovery. It also helps to prevent complications such as breast abscess and supports continued milk production.
(C) Encourage the client to wear a bra that is loose fitting:
While wearing a comfortable bra is important, a loose-fitting bra may not provide the necessary support for engorged or painful breasts. A well-fitting, supportive bra is usually recommended to provide comfort without being too tight, which can exacerbate symptoms.
(D) Limit the client's daily fluid intake:
Limiting fluid intake is not recommended and is not beneficial for treating mastitis. Adequate hydration is important for overall health and helps maintain milk supply. Encouraging the client to drink plenty of fluids is essential for recovery and continued breastfeeding.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.