The nurse is providing education to a client that is 3 hours postpartum after a vaginal delivery with a second-degree laceration.
Which of the following actions should the nurse include in the perineal care teaching? (Select all that apply.)

Choice A rationale

Encouraging the client to empty her bladder is a common practice to prevent uterine atony and excessive bleeding. However, in this scenario, the fundus is already midline and firm at the umbilicus, indicating that the uterus is well-contracted. Therefore, this action is not necessary.

Choice B rationale

Notifying the client’s provider is not required in this situation. The findings of a light amount of lochia rubra and a firm, midline fundus are normal for 6 hours postpartum. There are no signs of complications that would necessitate contacting the provider.

Choice C rationale

Documenting the findings and continuing to monitor the client is the appropriate action. The client’s condition is stable, and the findings are within the expected range for 6 hours postpartum. Ongoing monitoring will ensure that any changes in the client’s condition are promptly addressed.

Choice D rationale

Increasing the frequency of fundal massage is not needed in this case. The fundus is already firm and midline, indicating that the uterus is well-contracted. Excessive fundal massage can cause discomfort and is unnecessary when the uterus is already in a good position.

Choice A rationale

Washing hands before and after perineal care or voiding is essential to prevent infection. Proper hand hygiene reduces the risk of introducing bacteria to the perineal area, which is particularly vulnerable to infection postpartum.

Choice B rationale

Leaving the current pad on until it is fully saturated is not recommended. Changing pads frequently helps to maintain cleanliness and reduce the risk of infection. A saturated pad can harbor bacteria and increase the risk of infection.

Choice C rationale

Wiping the perineum thoroughly with a back-and-forth motion is not recommended. Instead, the perineum should be wiped from front to back to prevent the spread of bacteria from the rectal area to the perineal area, reducing the risk of infection.

Choice D rationale

Using a perineal squeeze bottle to cleanse the perineum is recommended. It helps to gently clean the area without causing irritation or discomfort. The warm water can also provide soothing relief to the perineal area.

Choice E rationale

Applying ice or cold packs to the perineum can help to reduce swelling and provide pain relief. The cold temperature constricts blood vessels, reducing inflammation and numbing the area to alleviate discomfort. .