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
A temperature of 37.8°C (100°F) 18 hours postpartum is slightly elevated but not necessarily indicative of a serious issue. It may require monitoring but is not the most urgent concern.
Choice B rationale
Abdominal pain during breastfeeding 8 hours postpartum is a common experience due to uterine contractions. While it may cause discomfort, it is not typically an urgent concern.
Choice C rationale
Not having a bowel movement 24 hours postpartum is not uncommon and does not usually require immediate attention. It can be addressed with dietary changes and other interventions.
Choice D rationale
Saturating one perineal pad over 2 hours 6 hours postpartum in a G5P4 client indicates a potential risk of postpartum hemorrhage. This is a more urgent concern that requires immediate assessment and intervention to prevent complications.
Correct Answer is C
Explanation
Choice A rationale
A Papanicolaou test, commonly known as a Pap smear, is used to detect cervical cancer and precancerous changes in the cervix. It does not detect herpes simplex type 1. Herpes simplex virus (HSV) testing is typically done through a swab of the lesion or blood tests to detect antibodies.
Choice B rationale
A glucose tolerance test is performed during pregnancy to screen for gestational diabetes, not to predict hyperglycemia in the baby. This test helps identify how well the mother’s body is managing glucose and ensures that both mother and baby remain healthy during pregnancy.
Choice C rationale
A multiple marker screening, also known as a triple or quad screen, is performed during pregnancy to identify potential neural tube defects, such as spina bifida, and chromosomal abnormalities like Down syndrome. This test measures specific substances in the mother’s blood to assess the risk of these conditions.
Choice D rationale
Group B streptococcus (GBS) screening is performed to detect the presence of GBS bacteria in the mother’s body, not to determine the presence of sexually transmitted infections (STIs). GBS can cause serious infections in newborns, so it is important to identify and treat it before delivery.