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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?

A.

Apply a corticosteroid cream to the perineal area twice daily.

B.

Increase the client’s fluid intake for 48 hours.

C.

Catheterize the client’s bladder.

D.

Offer an ice pack to the client during the first 24 hours.

Answer and Explanation

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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View Related questions

Correct Answer is B

Explanation

Choice A rationale

Acrocyanosis is a common finding in newborns and is not a sign of dehydration. It usually resolves on its own.

Choice B rationale

A capillary refill time greater than 3 seconds can indicate dehydration in a newborn. It suggests poor perfusion and fluid status.

Choice C rationale

Voiding four times in the past 24 hours is within the normal range for a newborn and does not indicate dehydration.

Choice D rationale

A flat soft anterior fontanel is normal in newborns and does not indicate dehydration. A sunken fontanel would be a sign of dehydration.

Correct Answer is D

Explanation

Choice A rationale

Providing additional hydration by offering glucose water is not recommended. Breast milk or formula should be the primary source of hydration for newborns.

Choice B rationale

Monitoring the newborn’s heart rate every 2 hours is not necessary for phototherapy. The focus should be on monitoring bilirubin levels, hydration status, and ensuring the newborn’s eyes are protected.

Choice C rationale

Applying a water-based lotion to the newborn’s skin every 4 hours is not recommended. Lotions can interfere with the effectiveness of phototherapy and may cause skin irritation.

Choice D rationale

Removing the newborn from phototherapy every 2 hours for breastfeeding is recommended. Frequent breastfeeding helps to promote bilirubin excretion and maintain hydration.

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