The nurse is explaining to a mother who had an episiotomy how to use a Peri bottle to clean herself after urination or bowel movement. Which information is correct?

"Flush the perineal area twice a day for 20 minutes"

"Use the whole Peri bottle of water to cleanse the perineum"

"First clean perineal area front to back with toilet paper

"Fill the Peri bottle with sterile water warmed to approximately 98 degrees F"

Answer and Explanation

The Correct Answer is B

a. "Flush the perineal area twice a day for 20 minutes" is incorrect because the Peri bottle should be used after each urination or bowel movement, not just twice a day.

b. "Use the whole Peri bottle of water to cleanse the perineum." The purpose of the Peri bottle is to thoroughly rinse the perineal area to keep it clean and reduce the risk of infection, especially after an episiotomy. Using the entire bottle ensures adequate cleansing.

c. "First clean perineal area front to back with toilet paper" is not correct as this should be done carefully to avoid contamination. It is generally recommended to use the Peri bottle directly to rinse and then gently pat dry with toilet paper or a clean cloth.

d. "Fill the Peri bottle with sterile water warmed to approximately 98 degrees F" is unnecessary; warm tap water is usually sufficient for this purpose.

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Correct Answer is C

No explanation

A. Check vital signs of a client who is being admitted with gestational hypertension. B. B. Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum. C. Observe an area of redness on the breast of a client who is 1 day postpartum. D. Assist with changing the perineal pad of a client following delivery.

Correct Answer is B

Explanation

A.Monitoring vital signs during the admission of a client with gestational hypertension requires nursing judgment and assessment skills.

B. Providing a sitz bath to a client with a fourth-degree laceration and is 2 days post- partum can be delegated to an AP. This task does not require the nurse's clinical judgment or assessment skills, and it can be safely performed by the AP following the nurse's instructions.

C.Observing an area of redness on the breast requires nursing assessment and intervention.

D.Changing the perineal pad of a client who has just been transferred from the labor ward is a task that should not be delegated to an assistive personnel (AP) since it is beyond their scope.This task requires assessment skills to evaluate the amount and type of lochia (postpartum vaginal discharge) and to monitor for signs of complications such as hemorrhage or infection. These assessments are within the scope of practice for a registered nurse.

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The nurse is explaining to a mother who had an episiotomy how to use a Peri bottle to clean herself after urination or bowel movement. Which information is correct?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is B

Explanation

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