A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply.)
Blot the perineal area dry after cleansing.
Perform hand hygiene before and after voiding.
Apply ice packs to the perineal area several times daily.
Clean the perineal area from front to back.
Wash the perineal area using a squeeze bottle of warm water after each voiding.
Correct Answer : A,B,D,E
A. Blotting the perineal area dry helps prevent moisture retention, reducing the risk of infection.
B. Performing hand hygiene before and after voiding helps prevent the introduction of bacteria into the perineal area.
C. Applying ice packs may help reduce swelling but is not a routine measure for preventing infection.
D. Cleaning the perineal area from front to back helps prevent the introduction of fecal bacteria into the urethra and vagina.
E. Washing the perineal area using a squeeze bottle of warm water after each voiding helps maintain cleanliness and prevent infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The nurse should not allow anyone other than the mother or the father to take the newborn to the mother's room. This is to prevent infant abduction, which is a serious threat in hospitals. The nurse should also verify the identity of the mother or the father before handing over the newborn. The nurse should instruct the grandmother to have the mother call and request for the newborn to be brought to her room.
B. This is incorrect because pushing the baby in a wheeled bassinet is not a secure way of transporting the newborn. The bassinet could be easily taken by someone else or accidentally rolled away. The nurse should always accompany the newborn when moving from one place to another.
C. This is incorrect because carrying the grandchild to the room is also not a secure way of transporting the newborn. The grandmother could be stopped by someone who claims to be a staff member and asked to hand over the newborn. The nurse should never let anyone carry the newborn without proper identification and authorization.
D. This is incorrect because showing photo identification is not enough to prove that the person is related to the newborn. The nurse should only allow the mother or the father to take the newborn, and only after verifying their identity with a wristband or a code. The nurse should not rely on photo identification alone, as it could be forged or stolen.
Correct Answer is A
Explanation
A. Vitamin K is a fat-soluble vitamin that is essential for blood clotting. Newborns have low levels of vitamin K because they do not have the intestinal bacteria that produce it. Therefore, they are given an injection of vitamin K shortly after birth to prevent bleeding disorders.
B. Vitamin K is not crucial for the breakdown of bilirubin.
C. Vitamin K primarily plays a role in blood clotting, not the production of white blood cells.
D. Vitamin K is not directly involved in the production of red blood cells.
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