Correct Answer: C

Rationale: Applying an ice pack to the perineum is the most appropriate action in this scenario. Ice causes vasoconstriction, providing relief by numbing the area and preventing edema. It is typically used within the first 12 to 24 hours after birth. Assisting the woman in taking a warm sitz bath is more suitable after 24 hours as warm water can be soothing. Administering an IV opioid analgesic is excessive; an anesthetic spray is more appropriate for surface discomfort. Contacting the registered nurse is unnecessary as applying an ice pack is within the nurse's scope and can effectively address the discomfort without escalation.

Correct Answer: A

Rationale: When preparing the physical environment for an interview with a client, it is crucial to ensure the client's comfort. Setting the room temperature at a comfortable level is essential for the client's well-being. Additionally, providing privacy, sufficient lighting, and removing distractions are crucial factors. It is recommended to maintain a distance of around 4 to 5 feet between the client and the nurse. Seating should be arranged so that the client and nurse are at eye level to facilitate effective communication and prevent barriers. Placing a chair across from the nurse's desk may create a physical barrier, positioning the client to face a strong light can be uncomfortable and distracting, and setting up seating so that the client and nurse are not at eye level may impede effective communication.

Correct Answer: D

Rationale: To assess vesicular breath sounds, the nurse should place the stethoscope over the peripheral lung fields. Vesicular breath sounds are heard in these areas where air flows through the smaller bronchioles and alveoli. Bronchovesicular breath sounds, not vesicular, are heard over the major bronchi. Bronchial (tracheal) breath sounds are heard over the trachea and larynx, not vesicular sounds. Breath sounds are not heard over the xiphoid process, making it an incorrect choice.

Correct Answer: B

Rationale: The Tinel sign is elicited by percussing at the location of the median nerve at the wrist. In carpal tunnel syndrome, this test can produce burning and tingling along the nerve's distribution. Choices A, C, and D are incorrect. Testing for the strength of each muscle joint and checking for repetitive movements in the joints involve different assessments unrelated to the Tinel sign. Asking the client to flex the wrist 90 degrees while holding the hands back to back is associated with the Phalen test, which is another evaluation for carpal tunnel syndrome.

Correct Answer: B

Rationale: Head lag should be completely resolved by 4 months of age. Continuing head lag at 6 months of age indicates the need for further developmental or neurological evaluation. Laying the infant on his stomach promotes muscle development of the neck and shoulder muscles, but because of the age of this child, a referral should be the first action. The findings are abnormal for a 6-month-old infant. Significant head lag can be seen in infants with Down syndrome and hypoxia, as well as neurological and other metabolic disorders. While some of these disorders might include developmental delays, stating this to the parents without a proper evaluation can cause unnecessary distress. The priority is to identify the cause of the head lag through a medical evaluation before discussing potential outcomes with the parents.