A nurse is caring for a postpartum person with a second-degree perineal tear. What is the most appropriate intervention for pain management?

Correct Answer: C

Rationale: The most appropriate intervention for pain management in a postpartum person with a second-degree perineal tear is administering non-pharmacological pain relief (Choice C). This includes methods such as sitz baths, warm compresses, and positioning techniques. These interventions are effective in reducing pain and promoting healing without the side effects associated with medications or invasive procedures. Oral pain medication (Choice A) may not be sufficient for managing the specific pain in this case. Administering an epidural analgesic (Choice B) is not appropriate postpartum, as it is typically used during labor for pain relief. Ice packs (Choice D) may provide temporary relief but do not address the underlying pain and healing process as effectively as non-pharmacological methods.

Correct Answer: A

Rationale: The correct answer is A: keep the cord dry and clean. This is because keeping the umbilical cord dry and clean helps prevent infection and promotes healing. Applying a sterile dressing (B) is unnecessary and may trap moisture, leading to infection. Using alcohol or iodine (C) is outdated and can delay cord separation. Applying a sterile dressing to the umbilicus (D) is not recommended as it can interfere with air circulation and healing. In summary, choice A is correct as it aligns with current best practices for umbilical cord care.

Correct Answer: A

Rationale: The correct answer is A: increase the IV fluid rate. This intervention helps to increase blood volume and improve blood pressure, addressing hypotension commonly caused by epidural anesthesia. Administering an epidural bolus (B) can worsen hypotension. Administering an analgesic (C) is not the priority in this situation. Increasing monitoring frequency (D) is important but addressing the underlying cause of low blood pressure is crucial.

Correct Answer: B

Rationale: The correct answer is B: apply gentle pressure to the perineum. This intervention helps to support the perineum and reduce the risk of perineal tearing during childbirth. Applying gentle pressure can slow down the baby's descent and allow the perineum to stretch gradually, reducing the likelihood of severe tearing. This intervention is important to promote a safe and controlled delivery. Incorrect answer explanations: A: Applying warm compresses may provide some comfort but does not specifically address the need to support the perineum during childbirth. C: Episiotomy should be considered only when necessary and not as a routine intervention when the perineum bulges. D: Perineal massage is typically done during the prenatal period to help prepare the perineum for childbirth but is not the most appropriate intervention when the perineum starts to bulge during labor.

Correct Answer: A

Rationale: The correct answer is A: Fever. In the first 24 hours postpartum, fever is the most concerning finding as it can indicate infection, such as endometritis or mastitis. Fever is a common early sign of infection and requires immediate assessment and intervention. Redness and swelling at the site (B) could be normal postpartum findings. Increased heart rate (C) may be a nonspecific response to stress or dehydration. Fatigue (D) is common postpartum but not typically indicative of infection in the first 24 hours. Fever warrants prompt attention due to the risk of serious complications if left untreated.