A nurse is reinforcing teaching with a client who is 12 hr postpartum and has an episiotomy. Which of the following instructions should the nurse include?

Cleanse the perineal area from back to front.

Wash the perineal area with povidone-iodine twice daily

Change the perineal pad with each void

"Wipe the perineal area with a soft cloth."

Answer and Explanation

The Correct Answer is C

Answer: C. Change the perineal pad with each void.

Rationale:

A) Cleanse the perineal area from back to front: Cleansing from back to front is not recommended as it increases the risk of introducing bacteria from the anal area to the perineal wound, potentially leading to infection. The correct technique is front-to-back cleansing to prevent contamination.

B) Wash the perineal area with povidone-iodine twice daily: Povidone-iodine is not typically recommended for regular perineal care postpartum, as it can disrupt normal flora and potentially irritate the healing tissues. Using warm water and mild soap is safer for cleansing the area.

C) Change the perineal pad with each void: Changing the perineal pad with each void helps maintain cleanliness and reduces moisture in the perineal area, decreasing the risk of infection and promoting comfort during the healing process of an episiotomy.

D) Wipe the perineal area with a soft cloth: Wiping the area can disrupt the stitches and may cause discomfort. Instead, clients are usually advised to gently pat dry or use a squirt bottle to cleanse, which reduces pressure on the healing tissue.

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Free Nursing Study Resources

Correct Answer is D

Explanation

The nurse should include the instruction to "Rehearse your escape route" in the safety plan for a client who reports partner violence. A safety plan is a personalized and practical plan on how to remain safe in an abusive relationship while preparing to leave when the timing is right and safe to do so . Rehearsing an escape route can help the client be prepared and know what to do in case they need to leave quickly.

Option a is incorrect because calling a shelter in another county may not be the most practical or eﬀective option for the client.

Option b is incorrect because leaving an abusive partner immediately may not always be the safest option for the client.

Option c is incorrect because keeping a packed bag by the front door may not be the most practical or eﬀective option for the client.

A. Flexes the client's aﬀected hip to 120 B. Adducts the client's aﬀected leg C. Checks the neurovascular status of the client's lower extremities every 6 hr D. Applies a sequential compression device to the client's lower extremities

Correct Answer is D

No explanation

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A nurse is reinforcing teaching with a client who is 12 hr postpartum and has an episiotomy. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about a safety plan for a client who reports partner violence. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following actions by the nurse demonstrates cost-eﬀective care?

Correct Answer is D

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