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 D
Explanation
Choice A rationale
An increase in lochia is not an indicator of the effectiveness of oxytocin. Lochia is the vaginal discharge after childbirth and its amount can vary.
Choice B rationale
The absence of breast pain is not related to the effectiveness of oxytocin, which is used to prevent postpartum hemorrhage by promoting uterine contractions.
Choice C rationale
An increase in blood pressure is not an expected outcome of oxytocin administration. Oxytocin primarily affects the uterus.
Choice D rationale
A firm fundus to palpation indicates that the uterus is contracting effectively, which is the desired effect of oxytocin administration to prevent postpartum hemorrhage.
Correct Answer is D
Explanation
Choice A rationale
The rubella vaccine should not be taken during pregnancy. It is a live attenuated vaccine, and there is a theoretical risk of harm to the developing fetus. Therefore, it is recommended to receive the vaccine before pregnancy.
Choice B rationale
The rubella vaccine is not recommended during each pregnancy. It is typically given as part of the MMR (measles, mumps, rubella) vaccine series in childhood, and immunity is usually lifelong. A booster dose is not needed during each pregnancy.
Choice C rationale
The rubella vaccine is not related to the Rh status of the baby. The vaccine is given to prevent rubella infection, which can cause serious birth defects if contracted during pregnancy.
Choice D rationale
The correct statement is that the client should avoid pregnancy for 28 days after receiving the rubella vaccine. This is to ensure that the live attenuated virus does not pose a risk to a developing fetus.