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 A
Explanation
Choice A rationale
Checking the identity of individuals who come to remove the baby from the room is crucial for preventing infant abduction and ensuring the safety of the newborn.
Choice B rationale
Matching the bracelet on the baby with the footprint record each shift is not a standard practice for newborn identification and safety.
Choice C rationale
Scanning the baby’s identification bracelet each time they are checked on is not a common practice and may not be feasible.
Choice D rationale
Wearing an electronic bracelet when out of the room is a safety measure, but it does not replace the need for parents to verify the identity of individuals handling their baby.
Correct Answer is D
Explanation
Choice A rationale
Serum bilirubin is not the priority test for hyperemesis gravidarum. It is more relevant for assessing liver function and jaundice.
Choice B rationale
Liver enzymes may be elevated in hyperemesis gravidarum, but they are not the priority test. The primary concern is dehydration and electrolyte imbalance.
Choice C rationale
A CBC can provide information on the client’s overall health, but it is not the priority test for hyperemesis gravidarum. The focus should be on assessing hydration status.
Choice D rationale
Urinalysis for ketones is the priority test because it helps assess the severity of dehydration and malnutrition. The presence of ketones indicates that the body is breaking down fat for energy, which is a sign of inadequate caloric intake.