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
Tetracycline is contraindicated in pregnancy due to its potential to cause fetal harm, including teeth discoloration and inhibition of bone growth.
Choice B rationale
Acyclovir is an antiviral medication used to treat herpes infections, not chlamydia.
Choice C rationale
Metronidazole is used to treat bacterial vaginosis and trichomoniasis, not chlamydia.
Choice D rationale
Amoxicillin is a safe and effective antibiotic for treating chlamydia in pregnant women. It is preferred due to its safety profile and effectiveness.
Correct Answer is A
Explanation
Choice A rationale
Warming the newborn’s heel for 5 to 10 minutes before the puncture increases blood flow, making it easier to collect a blood sample.
Choice B rationale
The outer aspect of the heel is the recommended site for puncture to avoid injury to the bone and nerves.
Choice C rationale
Leaving the heel open to the air after the puncture is not recommended as it can increase the risk of infection.
Choice D rationale
Applying an antiseptic after collecting the specimen is not necessary and can interfere with the blood sample.