Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
23. A postpartum nurse instructed a client on proper perineal care after delivery of a healthy neonate vaginally after a midline episiotomy. Which client activities should indicate to the nurse that the client has understood the instructions? Select all that apply.
. The client changes her peri pads every 8 hours.
. The client consistently uses the peri bottle to clean the perineum after each void or bowel movement.
. The client wipes from back to front after each bowel movement.
. The client sprays water from the peri bottle directly into the vagina.
. The client uses the antiseptic spray after rinsing with the peri bottle.
Test-Taking Tip
Select the two options that are correct steps when using the peri bottle.
Content Area: Maternity, Postpartum; Integrated Process: Nursing Process, Evaluation; Cognitive Level: Analysis; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is incorrect because the client needs to change her pads more frequently to stay fresh and help prevent infection. Changing pads about every 3 to 4 hours is the suggested interval for proper hygiene. Answer 2 is correct because consistently using the peri bottle to clean the perineum after each void or bowel movement demonstrates proper perineal care. The nurse should give instructions to keep the perineum clean to increase comfort and prevent infection. Using a peri bottle and water to rinse after each void or bowel movement helps keep the perineum clean and decreases the chance of infection. Answer 3 is incorrect because the client should wipe from front to back to decrease chances of infection due to transmitting bacteria from the rectum to the vagina. Answer 4 is incorrect because the client should spray water over the perineum and not directly into the vagina. Answer 5 is correct because perineal care should include using antiseptic spray after rinsing. The nurse should give instructions to keep the perineum clean to increase comfort and prevent infection. Using antiseptic spray after rinsing with the peri bottle helps to prevent infection and decreases perineal pain.