Difficulty: Medium
Average Score: 90%
Practice
A postpartum client presents with persistent, severe perineal pain and swelling following a vaginal delivery. On assessment, the nurse notes ecchymosis and tenderness of the perineum. Which nursing action is most appropriate?
Correct answer
C
Rationale
The most appropriate nursing action in this situation is to notify the healthcare provider immediately. The client presenting with persistent, severe perineal pain and swelling, along with ecchymosis and tenderness of the perineum, could be indicative of complications such as a perineal hematoma. A perineal hematoma is a collection of blood in the perineal tissues and can be a serious postpartum complication requiring prompt medical attention. Therefore, it is crucial to alert the healthcare provider so that appropriate assessment, management, and treatment can be initiated promptly. Applying ice packs or encouraging the client to sit on a donut cushion may not be sufficient in this situation, and administering additional analgesic medication should be done only after the healthcare provider has assessed and determined the cause of the symptoms.