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 C
Explanation
Choice A rationale
A temperature of 99.0°F (37.3°C) is within the normal range and is not specifically associated with cardiovascular system changes in the postpartum period. It is a common finding and does not indicate any specific cardiovascular changes.
Choice B rationale
A respiratory rate of 18/min is within the normal range for adults and is not specifically associated with cardiovascular system changes in the postpartum period. It is a common finding and does not indicate any specific cardiovascular changes.
Choice C rationale
An elevated white blood cell (WBC) count of 22,000/mm³ is a common finding in the postpartum period due to the body’s response to the stress of childbirth. This leukocytosis is a normal physiological response and is associated with the cardiovascular system changes during this period.
Choice D rationale
Urinary retention is not specifically associated with cardiovascular system changes in the postpartum period. It can occur due to various reasons, including the effects of anesthesia or trauma during delivery, but it is not a direct result of cardiovascular changes.