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 B
Explanation
Choice A rationale
Placing the newborn supine and applying pressure to the soles of the feet is not the correct method to elicit the Babinski reflex. This action does not stimulate the appropriate nerve pathways involved in the reflex.
Choice B rationale
Stroking upward on the lateral aspect of the sole of the newborn’s foot is the correct method to elicit the Babinski reflex. This action stimulates the plantar reflex, causing the big toe to extend upward and the other toes to fan out.
Choice C rationale
Pulling the newborn up by the wrist from a supine position is used to elicit the traction response, not the Babinski reflex. The traction response involves the newborn flexing their arms and attempting to lift their head.
Choice D rationale
Touching the corner of the newborn’s mouth elicits the rooting reflex, not the Babinski reflex. The rooting reflex causes the newborn to turn their head toward the stimulus and open their mouth.
Correct Answer is B
Explanation
Choice A rationale
Diazepam is a benzodiazepine used primarily for anxiety, muscle spasms, and seizures. It is not recommended for opioid use disorder during pregnancy due to potential risks to the fetus, including withdrawal symptoms and developmental issues.
Choice B rationale
Methadone is a long-acting opioid agonist used to treat opioid use disorder. It helps reduce withdrawal symptoms and cravings without producing the euphoria associated with opioid abuse. Methadone is considered safe for use during pregnancy and can improve maternal and fetal outcomes.
Choice C rationale
Naloxone is an opioid antagonist used to reverse opioid overdose. While it is crucial to have naloxone readily available for individuals with opioid use disorder to prevent overdose deaths, it is not a primary treatment for opioid use disorder during pregnancy.
Choice D rationale
Buprenorphine is a partial opioid agonist used to treat opioid use disorder. It is considered safe for use during pregnancy and can reduce withdrawal symptoms and cravings. However, methadone is often preferred due to its longer history of use and more extensive research on its safety during pregnancy.