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.
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Correct Answer is D
Explanation
Choice A rationale
Purchasing furniture for the baby’s room is a common and healthy behavior during pregnancy. It indicates that the client is preparing for the baby’s arrival and is excited about the new addition to the family. This behavior is generally seen as positive and supportive of the pregnancy.
Choice B rationale
Being unsure about wanting an epidural during labor is a normal concern for many pregnant individuals. It reflects the client’s consideration of pain management options and their desire to make an informed decision. This is not typically seen as a psychosocial concern.
Choice C rationale
The partner planning to attend birthing classes with the client is a positive sign of support and involvement in the pregnancy. It indicates that the partner is engaged and willing to participate in the childbirth process, which can be beneficial for the client’s emotional well-being.
Choice D rationale
Expressing uncertainty about whether an older child will accept the new baby can indicate underlying anxiety or stress about family dynamics and the impact of the new baby on existing relationships. This concern may require further exploration and support to ensure the client’s emotional health.
Correct Answer is A
Explanation
Choice A rationale
A positive Babinski reflex is characterized by the fanning out of the toes and the upward movement of the big toe when the sole of the foot is stroked. This reflex is normal in infants up to 2 years old and indicates an immature central nervous system. The presence of this reflex in older children or adults can indicate neurological issues.
Choice B rationale
Curling in of the toes when the sole of the foot is stroked is indicative of the plantar grasp reflex, not the Babinski reflex. The plantar grasp reflex is a different neurological response and does not indicate the same neurological development as the Babinski reflex.
Choice C rationale
No response when the sole of the foot is stroked could indicate a lack of neurological response or an issue with the sensory or motor pathways. This is not characteristic of a positive Babinski reflex and could be a sign of neurological impairment.
Choice D rationale
The big toe bending down when the sole of the foot is stroked is a normal response in older children and adults, known as the plantar reflex. This response indicates a mature central nervous system and is not characteristic of a positive Babinski reflex in infants.