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
Placing a newborn in the right lateral position is not recommended as it increases the risk of suffocation and sudden infant death syndrome (SIDS)4.
Choice B rationale
Placing a newborn in the left lateral position is also not recommended for the same reasons as the right lateral position.
Choice C rationale
Placing a newborn in the prone position (on their stomach) significantly increases the risk of SIDS and is not recommended.
Choice D rationale
Placing a newborn in the supine position (on their back) is the safest position for sleep and is recommended to reduce the risk of SIDS4.
Correct Answer is A
Explanation
Choice A rationale
A hemoglobin level of 9.5 g/dL is low for a full-term newborn and should be reported to the provider. Normal hemoglobin levels for newborns range from 14 to 24 g/dL4.
Choice B rationale
A white blood cell count of 10,000/mm³ is within the normal range for a newborn, which is typically between 9,000 and 30,000/mm³4.
Choice C rationale
A glucose level of 60 mg/dL is within the normal range for a newborn, which is typically between 40 and 60 mg/dL4.
Choice D rationale
A platelet count of 225,000/mm³ is within the normal range for a newborn, which is typically between 150,000 and 450,000/mm³4.