A nurse is reinforcing teaching about reducing the risk of perineal infection with a client who had a vaginal birth. Which of the following information should the nurse include in the teaching? (Select all that apply.)
Apply ice packs to the perineal area several times daily.
Sit on an inflatable donut to protect the perineum.
Perform hand hygiene before and after voiding.
Blot the perineal area dry after voiding.
Clean the perineal area from front to back.
Correct Answer : C,D,E
Choice A reason: While ice packs can help reduce swelling and discomfort, they are not essential for preventing infection.
Choice B reason: Sit on an inflatable donut to protect the perineum is incorrect, as this can increase pressure and blood flow to the perineum and delay healing. The nurse should advise the client to avoid sitting on hard or uneven surfaces and to use a pillow or a cushion for comfort.
Choice C reason: Perform hand hygiene before and after voiding is correct, as this can prevent contamination and infection of the perineal area. The nurse should instruct the client to wash their hands with soap and water or use an alcohol-based hand sanitizer before and after using the toilet.
Choice D reason: Blot the perineal area dry after voiding is correct, as this can keep the perineal area clean and dry and prevent irritation and infection. The nurse should instruct the client to use a clean, soft cloth or tissue and gently pat or blot the perineal area from front to back after voiding.
Choice E reason: Clean the perineal area from front to back is correct, as this can prevent bacteria from entering the vagina or urethra and causing infection. The nurse should instruct the client to use a peri-botle filled with warm water and squirt it over the perineal area from front to back after each voiding or bowel movement. The client should also change their perineal pad frequently and dispose of it properly.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Feeling for a full bladder is not the first action the nurse should take, although it is important to assess for bladder distension and urinary retention in postpartum clients. A full bladder can displace the uterus and increase the risk of uterine atony and hemorrhage.
Choice B reason:
Checking the client's fundus is the first action the nurse should take, as it can indicate the tone and position of the uterus. A firm and midline fundus indicates adequate uterine contraction and prevents excessive bleeding. A boggy or deviated fundus indicates uterine atony or retained placental fragments, which can cause hemorrhage.
Choice C reason:
Measuring the client's vital signs is not the first action the nurse should take, although it is important to monitor for signs of shock and infection in postpartum clients. Vital signs can be affected by various factors and do not provide a direct assessment of uterine status.
Choice D reason:
Requesting the provider perform a vaginal examination is not the first action the nurse should take, as it can introduce infection and trauma to the perineum. A vaginal examination is only indicated if there is suspicion of cervical or vaginal lacerations or retained placenta.
Correct Answer is B
Explanation
Choice B reason:
A fundus that is elevated and displaced from the midline indicates a full bladder, which can interfere with uterine contraction and increase the risk of hemorrhage. The nurse should assist the client to void or catheterize her if necessary.
Choice A reason:
Moderate swelling of the labia is a normal finding after vaginal delivery, and does not indicate a need to urinate. The nurse should apply ice packs and perineal pads to reduce edema and discomfort.
Choice C reason:
Moderate lochia rubra is a normal finding during the first 24 hr postpartum, and does not indicate a need to urinate. The nurse should monitor the amount and color of lochia, and change the perineal pads as needed.
Choice D reason:
A blood pressure of 130/84 mm Hg is within the normal range for a postpartum client, and does not indicate a need to urinate. The nurse should monitor the blood pressure for signs of hypertension or hypotension, which can indicate complications such as preeclampsia or hemorrhage.
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