The nurse is providing education to a client that is 3 hours postpartum after a vaginal delivery with a second-degree laceration. Which of the following actions should the nurse include in the perineal care teaching? (Select all that apply.)
Wash your hands before and after perineal care or voiding.
Leave your current pad on until it is fully saturated.
Wipe the perineum thoroughly with a back-and-forth motion.
Use a perineal squeeze bottle to cleanse the perineum.
Apply ice or cold packs to the perineum.
Correct Answer : A,D,E
Choice A rationale
Washing hands before and after perineal care or voiding is essential to prevent infection. Proper hand hygiene reduces the risk of introducing bacteria to the perineal area, which is particularly vulnerable to infection postpartum.
Choice B rationale
Leaving the current pad on until it is fully saturated is not recommended. Changing pads frequently helps to maintain cleanliness and reduce the risk of infection. A saturated pad can harbor bacteria and increase the risk of infection.
Choice C rationale
Wiping the perineum thoroughly with a back-and-forth motion is not recommended. Instead, the perineum should be wiped from front to back to prevent the spread of bacteria from the rectal area to the perineal area, reducing the risk of infection.
Choice D rationale
Using a perineal squeeze bottle to cleanse the perineum is recommended. It helps to gently clean the area without causing irritation or discomfort. The warm water can also provide soothing relief to the perineal area.
Choice E rationale
Applying ice or cold packs to the perineum can help to reduce swelling and provide pain relief. The cold temperature constricts blood vessels, reducing inflammation and numbing the area to alleviate discomfort.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
Choice A rationale
A heart rate of 125 bpm is significantly elevated and may indicate a postpartum complication such as infection, hemorrhage, or other underlying conditions. Tachycardia in the postpartum period warrants further assessment and intervention to identify and address the cause.
Choice B rationale
The fundus being palpable at the umbilicus is normal for 18 hours postpartum. The uterus gradually descends into the pelvis over the postpartum period, and its position at the umbilicus at this stage is expected.
Choice C rationale
A urine output of 3,000 mL in 24 hours is within the normal range for postpartum diuresis. Increased urine output is common as the body eliminates excess fluid accumulated during pregnancy.
Choice D rationale
Orthostatic hypotension can occur in the postpartum period due to blood volume changes and fluid shifts. While it requires monitoring, it is not as immediately concerning as tachycardia, which may indicate a more serious complication.
Correct Answer is C
Explanation
Choice A rationale
A high-fat diet is not recommended for breastfeeding mothers. While fats are an essential part of a balanced diet, excessive intake of high-fat foods can lead to unhealthy weight gain and may not provide the necessary nutrients for both the mother and the baby. Breastfeeding mothers should focus on a balanced diet that includes healthy fats, proteins, and carbohydrates to support their nutritional needs and milk production.
Choice B rationale
Stopping prenatal vitamins is not advisable for breastfeeding mothers. Prenatal vitamins contain essential nutrients such as folic acid, iron, and calcium that support the health of both the mother and the baby. Continuing to take prenatal vitamins can help ensure that breastfeeding mothers receive adequate nutrients, especially if their diet may not provide all the necessary vitamins and minerals.
Choice C rationale
Breastfeeding mothers need an additional 450-500 kCal per day to meet their increased energy requirements. This extra caloric intake supports milk production and helps the mother maintain her energy levels. The additional calories should come from a balanced diet that includes a variety of nutrient-dense foods.
Choice D rationale
Consuming only 8-16 oz of water per day is insufficient for breastfeeding mothers. Adequate hydration is crucial for milk production and overall health. Breastfeeding mothers should aim to drink at least 8-10 cups (64-80 oz) of water per day to stay hydrated and support their body’s increased fluid needs.