A nurse is caring for a postpartum client who had a vaginal delivery with an episiotomy.

Which action would help prevent infection of the perineal area?

Applying ice packs to the perineum for the first 24 hours.

Changing the perineal pad from back to front every 2 hours.

Spraying warm water over the perineum after each voiding or bowel movement.

Using an inflatable ring or pillow to sit on for comfort.

Answer and Explanation

The Correct Answer is C

The correct answer is C. Spraying warm water over the perineum after each voiding or bowel movement. This action would help prevent infection of the perineal area by keeping it clean and reducing the risk of bacterial contamination.

A is wrong because ice packs can only help reduce swelling and pain, but not prevent infection.

B is wrong because changing the pad from back to front can introduce bacteria from the rectum to the vagina and perineum, increasing the risk of infection. The correct way is to change the pad from front to back.

D is wrong because an inflatable ring or pillow can increase blood flow to the perineal area and delay healing, which can increase the risk of infection.

A firm surface is better for sitting after delivery.

Some other preventive measures for postpartum infections include washing hands before touching the perineal area, using only maxi pads and not tampons for postpartum bleeding, taking preventive antibiotics if prescribed, and contacting a doctor if symptoms of infection appear.

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Correct Answer is B

Explanation

The correct answer is choice B. Encourage the client to talk about her feelings and listen empathetically.

This action shows respect for the client’s emotions and helps her process her experience.

It also allows the nurse to provide support and reassurance.

Choice A is wrong because it dismisses the client’s feelings and implies that she should not be upset.

This can make the client feel guilty or invalidated.

Choice C is wrong because it blames the client for having unrealistic and unachievable expectations.

This can make the client feel ashamed or defensive.

Choice D is wrong because it suggests that the client needs professional counselling to cope with her emotions.

This can make the client feel stigmatized or abnormal.

Normal ranges for postpartum emotions vary depending on the individual and the circumstances.

However, some signs of postpartum depression or post-traumatic stress disorder include persistent sadness, anxiety, anger, guilt, flashbacks, nightmares, insomnia, loss of interest, difficulty bonding with the baby, or thoughts of harming oneself or the baby.

These symptoms should be reported to a healthcare provider as soon as possible.

A. Advanced maternal age B. Full-term gestation C. Absence of medical or obstetric complications D. Lack of uterine contractions before 37 weeks of gestation

Correct Answer is A

Explanation

Advanced maternal age is a risk factor for preterm labor, which occurs when regular contractions begin to open the cervix before 37 weeks of pregnancy.

Preterm labor can lead to premature birth, which can have serious health consequences for the baby.

Choice B is wrong because full-term gestation is not a risk factor for preterm labor.Full-term gestation means that the pregnancy lasts between 39 and 40 weeks, which is the ideal duration for the baby’s development.

Choice C is wrong because absence of medical or obstetric complications is not a risk factor for preterm labor.Some medical or obstetric complications that can increase the risk of preterm labor include urinary tract infections, high blood pressure, bleeding from the vagina, placenta previa, diabetes and blood clotting problems.

Choice D is wrong because lack of uterine contractions before 37 weeks of gestation is not a risk factor for preterm labor.Uterine contractions are a sign of preterm labor, not a cause of it.

Some other risk factors for preterm labor that the nurse should include in the discussion are:

• Previous preterm delivery or preterm labor

• Multiple gestation (twins, triplets or more)

• Abnormalities of the reproductive organs, such as a short cervix

• Ethnicity (African American and American Indian/Alaska Native mothers have higher rates of preterm birth than white mothers)

• Age of the mother (women younger than 18 are more likely to have a preterm delivery)

• Tobacco use and substance abuse

• Short time period between pregnancies (less than 18 months)

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A nurse is caring for a postpartum client who had a vaginal delivery with an episiotomy. Which action would help prevent infection of the perineal area?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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A nurse is caring for a postpartum client who had a vaginal delivery with an episiotomy.

Which action would help prevent infection of the perineal area?