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.
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Correct Answer is ["A","C","D","F"]
Explanation
Choice A rationale
A headache that is not relieved by hydration, rest, or over-the-counter medication can be a sign of postpartum preeclampsia, a serious condition that can occur after childbirth. Postpartum preeclampsia is characterized by high blood pressure and can lead to seizures, stroke, and other complications if not treated promptly.
Choice B rationale
Brownish red or pink lochia at 7 days postpartum is a normal finding. Lochia is the vaginal discharge that occurs after childbirth, and it typically changes color from bright red to pink or brownish red as the healing process progresses.
Choice C rationale
Chills and fever greater than 100.4°F (38.0°C) can indicate an infection, such as endometritis, which is an infection of the uterine lining. This condition requires prompt medical evaluation and treatment with antibiotics to prevent complications.
Choice D rationale
Feelings or thoughts of harming oneself or the infant are indicative of postpartum depression or postpartum psychosis, both of which are serious mental health conditions that require immediate attention and intervention from a healthcare provider.
Choice E rationale
Increased urinary output is a common postpartum finding as the body eliminates excess fluid retained during pregnancy. It is not typically a sign of a complication.
Choice F rationale
Redness, pain, or tenderness in the calf can be a sign of deep vein thrombosis (DVT), a blood clot that can occur in the legs. DVT is a serious condition that requires immediate medical evaluation and treatment to prevent the clot from traveling to the lungs and causing a pulmonary embolism.
Correct Answer is B
Explanation
Choice A rationale
A 29-year-old G3P3003 with an uncomplicated SVD at term and a supportive family environment is less likely to experience difficulties in transitioning to motherhood. The presence of her husband and older daughter provides a strong support system, which is beneficial for her adjustment.
Choice B rationale
A 37-year-old G3P1112 with worsening preeclampsia, induced at 34 weeks, currently on Magnesium Sulfate, and with a baby in the NICU, faces multiple stressors. The medical complications, preterm delivery, and separation from her baby due to NICU admission increase her risk for a difficult transition to motherhood. The use of Magnesium Sulfate can also affect her physical and emotional well-being.
Choice C rationale
A 31-year-old G3P2012 with a history of depression and a husband who is deployed faces significant challenges. The history of depression increases her risk for postpartum depression, and the absence of her husband can lead to feelings of isolation and increased stress.
Choice D rationale
A 16-year-old G1P1001 who delivered via cesarean section is at risk due to her young age and the surgical delivery. Adolescents may have less experience and resources to cope with the demands of motherhood, and the recovery from a cesarean section can add to the physical and emotional challenges.
Choice E rationale
A 20-year-old G1P1001 with an uncomplicated SVD and the presence of her boyfriend is less likely to face significant difficulties. The uncomplicated delivery and the support of her boyfriend provide a stable environment for her transition to motherhood. .