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 D
Explanation
Choice A rationale
Using a bladder scanner to assess for urinary retention is a non-invasive and appropriate intervention. It helps determine the volume of urine in the bladder and can guide further management. This method avoids unnecessary catheterization and reduces the risk of infection.
Choice B rationale
Catheterizing to empty the bladder is a common intervention for urinary retention. However, it should be done with caution and only when necessary to avoid the risk of infection. In this scenario, it is not contraindicated but should be considered after other non-invasive methods have been tried.
Choice C rationale
Placing peppermint oil on a cotton ball and placing it in the urinary “hat” while the client is on the toilet is a non-invasive method that can help stimulate urination through the scent of peppermint. This method is safe and can be effective for some clients.
Choice D rationale
Assisting the client back to bed and telling her to try to void again in 2 hours is contraindicated because it delays the intervention for a distended bladder. A distended bladder can cause discomfort and potential complications, so timely intervention is necessary.
Correct Answer is A
Explanation
Choice A rationale
An intrauterine device (IUD) is one of the most reliable methods of contraception. It is a small, T-shaped device inserted into the uterus by a healthcare provider. IUDs can be hormonal or non-hormonal (copper). Hormonal IUDs release progestin, which thickens cervical mucus to prevent sperm from reaching the egg and thins the uterine lining to prevent implantation. Copper IUDs release copper ions, which are toxic to sperm. Both types of IUDs are over 99% effective and can last for several years, making them a highly reliable form of contraception.
Choice B rationale
Oral contraceptives, commonly known as birth control pills, are also effective but require daily adherence. They contain hormones (estrogen and progestin) that prevent ovulation, thicken cervical mucus, and thin the uterine lining. However, their effectiveness can decrease with missed doses, certain medications, or gastrointestinal disturbances. With typical use, their effectiveness is around 91%, meaning 9 out of 100 women may become pregnant each year.
Choice C rationale
Male condoms are a barrier method of contraception that prevent sperm from entering the uterus. They are also effective in preventing sexually transmitted infections (STIs). However, their effectiveness can be compromised by improper use, breakage, or slippage. With typical use, male condoms are about 85% effective, meaning 15 out of 100 women may become pregnant each year.
Choice D rationale
A diaphragm with spermicide is a barrier method of contraception. The diaphragm is a shallow, dome-shaped cup inserted into the vagina to cover the cervix, and spermicide is applied to kill sperm. Its effectiveness depends on correct and consistent use. With typical use, diaphragms are about 88% effective, meaning 12 out of 100 women may become pregnant each year. Additionally, diaphragms do not protect against STIs.