A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply.)

Blot the perineal area dry after cleansing.

Perform hand hygiene before and after voiding.

Apply ice packs to the perineal area several times daily.

Clean the perineal area from front to back.

Wash the perineal area using a squeeze bottle of warm water after each voiding.

Answer and Explanation

Correct Answer : A,B,D,E

A.   Blotting the perineal area dry helps prevent moisture retention, reducing the risk of infection.
B.   Performing hand hygiene before and after voiding helps prevent the introduction of bacteria into the perineal area.
C. Applying ice packs may help reduce swelling but is not a routine measure for preventing infection.
D.   Cleaning the perineal area from front to back helps prevent the introduction of fecal bacteria into the urethra and vagina.
E.   Washing the perineal area using a squeeze bottle of warm water after each voiding helps maintain cleanliness and prevent infection.

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Correct Answer is C

Explanation

A. A hot pack to the perineum can be offered after 24 hours, but not before, as heat can increase bleeding.
B. A warm sitz bath can be offered after 24 hours, but not before, as heat can increase bleeding and infection risk.
C. The nurse should also apply an ice pack to the perineum for 20 minutes every 4 hours to reduce swelling and inflammation.
D. Providing a squeeze bottle of antiseptic solution is more related to perineal hygiene rather than pain relief.

A. Assess the client’s uterine fundus. B. Assist the client on a bedpan to urinate. C. Increase the client’s fluid intake. D. Prepare to administer oxytocic medication.

Correct Answer is A

Explanation

A. The priority is to assess the client's uterine fundus to determine if it is well-contracted. Excessive bleeding could be indicative of uterine atony, and prompt assessment is crucial for intervention.
B. Assisting the client on a bedpan to urinate is a secondary intervention. While a distended bladder can contribute to uterine atony, assessing the fundus comes first to determine the cause.
C. Increasing fluid intake is important for postpartum recovery, but it is not the immediate priority in this situation.
D. Preparing to administer oxytocic medication may be necessary if uterine atony is identified during the fundal assessment. However, assessing the fundus comes first to guide appropriate interventions.

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A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take?

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Explanation

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Correct Answer is A

Explanation

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