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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. The ball of the foot is not recommended for heelstick procedures.
B. The outer aspect of the heel is the preferred site. This area has fewer nerve endings and less risk of damaging the bone or cartilage.
C. The area below the fifth toe is not a standard site for a heelstick.
D. The walking surface of the heel should be avoided since it is prone to infection, more sensitive, and may interfere with walking.

A. Recognize the woman's limited attention span by giving her written materials to read when she is home. B. Provide time for the mother to reflect on the events of her labor and delivery. C. Promote maternal independence by encouraging her to meet her own hygiene and comfort needs. D. Foster an active role in the baby's care.

Correct Answer is B

Explanation

A. This is not appropriate for the taking-in stage, as the woman may not be ready to absorb new information or focus on self-care. She may need more verbal instruction and demonstration from the nurse.
B. The taking-in stage is a period of passive, dependent behavior in which the woman reviews her childbirth experience and adjusts to the new role of motherhood. She may need to talk about her labor and delivery repeatedly and seek reassurance from others. The nurse should listen attentively and validate her feelings.
C. This is more suitable for the taking-hold stage, which occurs after the taking-in stage. In this stage, the woman becomes more active and independent, and shows interest in learning how to care for herself and her baby.
D. This is also more appropriate for the taking-hold stage, when the woman develops confidence and competence in her maternal role. In the taking-in stage, she may be more focused on her own needs and rely on others to care for the baby.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The most serious complication of an infant heelstick is necrotizing osteochondritis resulting from lancet penetration of the bone. What approach should the nurse take when performing the test to prevent this complication?

Correct Answer is B

Explanation

A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment after childbirth. Recognizing the needs of women during this stage, how should the nurse respond?

Correct Answer is B

Explanation

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