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 B
Explanation
Choice A reason: Request the RN perform a cervical examination is incorrect, as this action is not indicated for a client who has a history of genital herpes. A cervical examination can introduce infection and trauma to the cervix and increase the risk of viral shedding and transmission to the fetus. The nurse should avoid performing or requesting a cervical examination unless absolutely necessary.
Choice B reason: Initiate fetal monitoring for baseline and changes is correct, as this action is appropriate for any client who is in labor. Fetal monitoring can provide information about the fetal heart rate, variability, accelerations, decelerations, and contractions. The nurse should monitor the fetal status continuously and report any abnormal findings to the provider.
Choice C reason: Prepare for a vaginal birth is incorrect, as this action may not be possible for a client who has a history of genital herpes. A vaginal birth can expose the fetus to the herpes virus and cause neonatal infection, which can be life-threatening. The nurse should assess the client for signs of active lesions or prodromal symptoms and prepare for a cesarean birth if indicated.
Choice D reason: Administer antibiotics is incorrect, as this action is not effective for a client who has a history of genital herpes. Genital herpes is caused by a virus, not a bacteria, and antibiotics have no effect on viral infections. The nurse should administer antiviral medications as prescribed to reduce viral shedding and transmission to the fetus.
Correct Answer is B
Explanation
Choice A reason:
A warm sitz bath can promote healing and comfort, but it is not recommended until 24 hr after delivery, as it can increase swelling and bleeding.
Choice B reason:
An ice pack can reduce inflammation and pain by causing vasoconstriction and numbing the area. It should be applied for 20 minutes at a time, with a cloth barrier between the skin and the ice.
Choice C reason:
A soft pillow under the client's butocks can increase pressure on the perineum and worsen the pain. The client should be encouraged to lie on her side or sit in a semi-Fowler's position.
Choice D reason:
A heating lamp can dry out the wound and delay healing. It can also cause burns and discomfort. It should be avoided for episiotomy care.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today