A nurse on a postpartum unit is reinforcing discharge teaching for a client who had an episiotomy. Which of the following statements by the client indicates an understanding of the teaching?
“I will use a sitz bath at least once a day."
“I will check the amount of bleeding with every other pad change”
“I will wash my perineum with mild soap and warm water every other day?”
“I will change my pad at least three times a day”
The Correct Answer is D
A. "I will use a sitz bath at least once a day.": Sitz baths should be used more frequently, typically several times a day, to promote perineal healing, relieve discomfort, and reduce swelling after an episiotomy. Limiting it to once daily may not provide adequate relief or hygiene support.
B. "I will check the amount of bleeding with every other pad change": The amount of lochia (postpartum bleeding) should be checked with every pad change, not every other. Monitoring bleeding closely helps detect signs of hemorrhage or infection early, ensuring prompt intervention if abnormalities are found.
C. "I will wash my perineum with mild soap and warm water every other day.": Perineal hygiene should be performed daily, and often multiple times a day, especially after urination or bowel movements. Washing every other day is insufficient and could increase the risk of infection at the episiotomy site.
D. "I will change my pad at least three times a day": Changing the perineal pad at least three times daily, or more often as needed, maintains cleanliness, helps prevent infection, and allows for regular monitoring of lochia and healing. This statement demonstrates good understanding of postpartum perineal care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Administer the tablet to the client with applesauce: Administering the tablet with a small amount of soft food like applesauce can help facilitate swallowing without altering the integrity of the enteric coating. This method eases the swallowing process while ensuring the medication is delivered properly.
B. Position the client at a 45-degree angle: Clients who have difficulty swallowing should be positioned in an upright 90-degree sitting position, not at 45 degrees, to reduce the risk of aspiration and promote safer swallowing mechanics.
C. Crush the tablet and mix it in pudding for the client: Enteric-coated tablets should never be crushed, as crushing destroys the protective coating designed to prevent the medication from being released in the stomach, potentially causing irritation or reducing drug effectiveness.
D. Instruct the client to tilt their head back when swallowing: Tilting the head back increases the risk of choking and aspiration, especially in clients with swallowing difficulties. It is safer to encourage tucking the chin slightly down when swallowing to help protect the airway.
Correct Answer is D
Explanation
A. A toddler who has periorbital cellulitis and has an axillary temperature of 37.6°C (99.7°F): A mild temperature in the context of periorbital cellulitis is expected and not an immediate emergency. Although periorbital cellulitis can be serious, this temperature alone does not demand immediate action over other critical symptoms.
B. An adolescent who has influenza and reports a headache of 6 on a scale of 0 to 10: A headache with influenza is common and requires monitoring, but unless there are signs of severe neurological involvement, it is not the highest priority compared to potential circulatory compromise.
C. An infant who had a pyloromyotomy 12 hr ago and spit up after the last feeding: Mild vomiting or spitting up is common following a pyloromyotomy and is not unusual within the first 24 hours postoperatively. It generally does not require immediate intervention unless persistent or worsening.
D. A child who had a cast placed 4 hr ago and reports numbness in the affected extremity: Numbness may indicate impaired circulation or nerve compression, a sign of possible compartment syndrome. This is a surgical emergency that can result in permanent damage if not promptly assessed and treated.
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