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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse should apply a heat pack 5 to 10 minutes prior to the procedure when planning to obtain blood from a newborn via a heel stick. This helps to increase blood flow to the area and makes it easier to obtain the specimen.
a) Puncturing the heel to a depth of 4 mm is too deep and can cause injury to the newborn. The recommended depth for a heel stick is 2.4 mm or less.
b) Withholding feeding prior to collecting the specimen is not necessary.
d) Elevating the newborn's foot for 15 minutes following the procedure is not necessary.
Correct Answer is B
Explanation
Explanation:
The nurse should respond by recommending that the parent avoids administering aspirin to the child. The use of aspirin in children, especially those under the age of 18, is associated with the risk of developing Reye's syndrome, a rare but serious condition that affects the liver and brain. It is important to educate parents about the potential risks of using aspirin in children, particularly when they have a fever. Instead, the nurse should advise the parent to use appropriate dosages of acetaminophen or ibuprofen based on the child's weight and follow the label directions for administration.
Option a suggests following the label directions based on the child's weight, which may not specifically address the use of aspirin in children and the risk of Reye's syndrome. Option c, stating that the child will require an antibiotic if she develops a fever, is incorrect because antibiotics are not indicated for all fevers and should only be prescribed if there is an underlying bacterial infection. Option d, suggesting that the child can have two baby aspirins every 4 hours, is incorrect and contradicts the recommendation to avoid administering aspirin to the child.
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