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    Vati PN Comprehensive Predictor Proctored Exam

    A nurse is reinforcing teaching with a client who is 12 hr postpartum and has an episiotomy. Which of the following instructions should the nurse Include?

    Explanation & Rationale

    A. Cleanse the perineal area from back to front: Perineal hygiene after delivery should be performed from front to back to prevent transfer of gastrointestinal flora, such as Escherichia coli, to the episiotomy site or urinary tract. Cleansing from back to front increases the risk of wound contamination and postpartum infection. B. Wash the perineal area with povidone-iodine twice daily: Routine use of antiseptic solutions such as povidone-iodine is not recommended for standard episiotomy care. These solutions can irritate healing tissue and disrupt normal skin flora. Gentle cleansing with warm water using a peri-bottle after voiding or defecation is typically advised. C. Change the perineal pad with each void: Lochia provides a moist environment that can promote bacterial growth and increase infection risk at the episiotomy site. Changing the perineal pad frequently, especially after each void, helps maintain dryness, reduce bacterial proliferation, and support wound healing. D. Wipe the perineal area with a soft towel: The perineal area should be gently patted dry rather than wiped to avoid mechanical trauma to the sutured episiotomy site. Wiping can place tension on the sutures and disrupt tissue approximation during the early stages of healing.

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