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 A

Explanation

A. Vitamin K is a fat-soluble vitamin that is essential for blood clotting. Newborns have low levels of vitamin K because they do not have the intestinal bacteria that produce it. Therefore, they are given an injection of vitamin K shortly after birth to prevent bleeding disorders.
B. Vitamin K is not crucial for the breakdown of bilirubin.
C. Vitamin K primarily plays a role in blood clotting, not the production of white blood cells.
D. Vitamin K is not directly involved in the production of red blood cells.

A. Confirming that the newborn is at least 24 hours old. B. Obtaining a syringe with a 25-gauge, 5/8-inch needle for medication administration. C. Assessing the dorsogluteal muscle as the preferred site for injection. D. Confirming that the newborn's mother has been infected with the HBV.

Correct Answer is B

Explanation

A. Confirming that the newborn is at least 24 hours old is not a requirement for administering the HBV vaccine. The vaccine can be given to newborns shortly after birth, typically within 12 hours.
B. Obtaining a syringe with a 25-gauge, 5/8-inch needle for medication administration is correct. This needle size is appropriate for administering vaccines intramuscularly to newborns.
C. Assessing the dorsogluteal muscle as the preferred site for injection is incorrect; the ventrogluteal or vastus lateralis muscles are recommended for intramuscular injections in infants. The dorsogluteal site is not preferred for young children due to the risk of sciatic nerve injury.
D. Confirming that the newborn's mother has been infected with the HBV is not necessary for administering the vaccine, although if the mother is infected, the newborn should receive the HBV vaccine and hepatitis B immunoglobulin (HBIG) within 12 hours of birth.

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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

The nurse is cognizant of which information related to the administration of vitamin K?

Correct Answer is A

Explanation

The nurse is preparing to administer a hepatitis B virus (HBV) vaccine to a newborn. Which intervention by the nurse is correct?

Correct Answer is B

Explanation

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