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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Encourage the client to nurse more frequently so her milk will come in is incorrect, as this action is not related to the data collected by the nurse. The nurse notes that the client's breasts are soft, which indicates that the milk has not come in yet. This is normal and expected for a client who is 14 hr postpartum, as milk production usually begins around 72 to 96 hr after birth. The nurse should encourage the client to nurse frequently and effectively to stimulate milk production and prevent engorgement.
Choice B reason: Increase IV fluids is incorrect, as this action is not indicated by the data collected by the nurse. The nurse notes that the client's vital signs are within normal limits, except for a slight temperature elevation. Increasing IV fluids can cause fluid overload and electrolyte imbalance in the client. The nurse should maintain the IV fluids at the prescribed rate and monitor the client's intake and output.
Choice C reason: Ask the client to empty her bladder is correct, as this action is indicated by the data collected by the nurse. The nurse notes that the client's fundus is firm but slightly deviated to the right, which suggests bladder distension. A full bladder can interfere with uterine contraction and involution and increase the risk of hemorrhage and infection. The nurse should assist the client to empty their bladder and reassess the fundal position.
Choice D reason: Report the client's temperature elevation is incorrect, as this action is not necessary for a slight temperature elevation in a postpartum client. The nurse notes that the client's temperature is 37.7° C (100° F), which is slightly above normal but within the range of expected findings for a postpartum client. A mild temperature elevation in the first 24 hr after birth can be due to dehydration, exertion, or hormonal changes and does not indicate infection. The nurse should encourage oral fluid intake and monitor the temperature every 4 hr.
Correct Answer is B
Explanation
Choice A reason:
Dinoprostone stimulates uterine contractions is incorrect, as this is not the primary purpose of the medication. Dinoprostone is a prostaglandin that can induce labor by ripening the cervix and enhancing uterine contractility, but it is not used solely for stimulating contractions.
Choice B reason:
Dinoprostone promotes softening of the cervix is correct, as this is the main purpose of the medication. Dinoprostone is used to prepare the cervix for labor by increasing its softness, dilation, and effacement. This can facilitate the descent of the fetus and shorten the duration of labor.
Choice C reason:
Dinoprostone relaxes uterine contractions is incorrect, as this is the opposite effect of the medication. Dinoprostone can increase uterine tone and frequency, which can help initiate or augment labor. The nurse should monitor the client for signs of uterine hyperstimulation or fetal distress.
Choice D reason:
Dinoprostone assists with ending the pregnancy is incorrect, as this is not the intended use of the medication. Dinoprostone can be used to terminate a pregnancy in some cases, such as fetal demise or missed abortion, but it is not routinely used for this purpose. The nurse should explain to the client that dinoprostone is used to induce labor and not to end a pregnancy.
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