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. Uterine tetany and overproduction of oxytocin are not typically associated with subinvolution.
B. Multiple gestation and postpartum hemorrhage may contribute to uterine atony but not necessarily subinvolution.
C. The most common causes of subinvolution are retained placental fragments and infection.
D. Postpartum hemorrhage may contribute to uterine atony but is not a direct cause of subinvolution.

A. Document the findings and continue to monitor the client. B. Encourage the client to empty her bladder. C. Increase the frequency of fundal massage. D. Notify the client’s provider.

Correct Answer is A

Explanation

A. The presence of lochia rubra with small clots in the immediate postpartum period is expected. The firm and midline fundus indicates appropriate uterine contraction. Continued monitoring is appropriate.
B. Encouraging the client to empty her bladder is a valid intervention, but it is not the priority in this situation.
C. Increasing the frequency of fundal massage is unnecessary, as the fundus is already firm.
D. Notifying the provider is not necessary based on the described findings, as they are within the expected range.

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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

What are the most common causes for subinvolution of the uterus?

Correct Answer is C

Explanation

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?

Correct Answer is A

Explanation

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