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. Webbing typically refers to the presence of extra skin between body parts and is not associated with uneven skinfolds on the buttocks or a clunk during the Ortolani maneuver.
B. Clubfoot refers to a deformity of the foot and is not associated with uneven skinfolds on the buttocks or hip abnormalities.
C. Uneven skinfolds on the buttocks and a clunk during the Ortolani maneuver are indicative of hip dysplasia in a newborn.
D. Polydactyly refers to the presence of extra fingers or toes and is unrelated to the described findings.

A. Breasts soft and non-tender B. Urine output of 3,000 mL in 12 hr C. Fundus palpable at the umbilicus D. Heart rate 128/min

Correct Answer is D

Explanation

A. Soft and non-tender breasts are a normal finding in the early postpartum period.
B. A urine output of 3,000 mL in 12 hours is within the normal range.
C. A fundus palpable at the umbilicus may be normal within the first few hours after childbirth.
D. A heart rate of 128/min may indicate a postpartum complication, such as hemorrhage or infection, and requires further assessment.

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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

While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a clunk when performing the Ortolani maneuver. These findings are likely indicative of what?

Correct Answer is C

Explanation

A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Correct Answer is D

Explanation

A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?

The nurse is caring for an infant who is small for her gestational age (SGA). Which intervention is of highest priority for this infant who is at risk for hypoglycemia?

A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?

A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data?

A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make?