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 A
Explanation
Choice A reason:
Fetal position is persistent occiput posterior is correct, as this position can cause difficult, prolonged labor and severe backache. The occiput posterior position means that the back of the fetal head is facing the maternal sacrum, which can result in poor alignment and descent, increased pressure on the maternal sacrum and nerves, and increased risk of perineal trauma. The nurse should encourage the client to change positions frequently, use pelvic rocking exercises, apply counterpressure to the sacrum, and administer analgesics as needed.
Choice B reason:
Fetal attitude is in general flexion is incorrect, as this attitude can facilitate normal labor and delivery. The fetal attitude refers to the degree of flexion or extension of the fetal head and limbs in relation to the fetal trunk. General flexion means that the fetal head is flexed on the chest, the arms are crossed over the chest, and the legs are flexed at the knees. This attitude allows the smallest diameter of the fetal head to pass through the birth canal.
Choice C reason:
Fetal lie is longitudinal is incorrect, as this lie can facilitate normal labor and delivery. The fetal lie refers to the relationship between the long axis of the fetus and the long axis of the mother. Longitudinal lie means that both axes are parallel, which allows for either a vertex (head-first) or a breech (butocks-first) presentation.
Choice D reason:
Maternal pelvis is gynecoid is incorrect, as this pelvis can facilitate normal labor and delivery. The maternal pelvis refers to the shape and size of the bony pelvis that affects the passage of the fetus. Gynecoid pelvis is the most common and favorable type for vaginal birth, as it has a rounded inlet, a wide pubic arch, and adequate outlet dimensions.
Correct Answer is C
Explanation
Choice A reason: "You will experience urinary retention." is incorrect, as this statement does not describe a sign preceding the onset of labor. Urinary retention can occur during labor due to pressure from the fetal head or epidural anesthesia, but it is not a sign that labor is imminent. The nurse should encourage the client to void frequently and monitor their bladder status.
Choice B reason: "You will have a decrease in vaginal discharge." is incorrect, as this statement does not describe a sign preceding the onset of labor. Vaginal discharge can increase before labor due to cervical ripening and dilation, which can cause bloody show or mucus plug loss. The nurse should educate the client about normal and abnormal vaginal discharge and when to report it.
Choice C reason: "You will experience a surge of energy." is correct, as this statement describes a sign preceding the onset of labor. A surge of energy, also known as nesting instinct, can occur before labor due to hormonal changes or psychological factors. The nurse should advise the client to conserve their energy and rest as much as possible before labor.
Choice D reason: "You will have a weight gain of 0.5 to 1.5 kilograms." is incorrect, as this statement does not describe a sign preceding the onset of labor. Weight gain can occur during pregnancy due to fetal growth, fluid retention, or increased caloric intake, but it is not a sign that labor is imminent. The nurse should monitor the client's weight and fluid balance and report any sudden or excessive weight gain that may indicate preeclampsia or other complications.
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