Today’s NCLEX-RN® question of the day focuses on perineal care and identifying and reporting any findings that require immediate review. Do you know the answer? Let’s find out!

The nurse in the step-down medical unit has performed perineal care on several newly admitted patients. Which finding should the nurse report immediately to the healthcare provider?

A.

Medical-style illustration of external female genital anatomy (the vulva), showing the labia, clitoral area, vaginal opening, and surrounding structures, with a small highlighted lesion on one side for educational or clinical reference.

B.

Medical-style illustration of the anal region showing surrounding skin held apart with gloved hands and a red, irritated vertical area around the anus, indicating inflammation or injury for clinical or educational purposes.

C.

Medical-style illustration of external male genital anatomy, showing the penis and scrotum in a simplified, neutral anatomical depiction for educational purposes.

D.

Medical-style illustration of the anal region with gloved hands holding the surrounding skin apart, showing a small, localized lesion or inflamed area at the anal opening for clinical or educational reference.

Scroll down for the correct answer!

The correct answer to today’s NCLEX® Question is…

A.

Medical-style illustration of external female genital anatomy (the vulva), showing the labia, clitoral area, vaginal opening, and surrounding structures, with a small highlighted lesion on one side for educational or clinical reference.

Rationale: If the nurse identifies abnormal lesions, such as a vulvar growth, it should be reported to the healthcare provider immediately as it could indicate cancer.

Main Takeaway

After the process of perineal care, the nurse should document any new skin rashes, redness, swelling or tenderness, peculiar odors, discharge, or bleeding from the vagina, penis, or the anus. If the nurse identifies abnormal lesions, such as a vulvar growth, it should be reported to the healthcare provider immediately as it could indicate cancer. Although perineal irritation and hemorrhoids are abnormal, the vulvar growth takes precedence and should be reported first.

Incorrect Answer Explanations

B.

Medical-style illustration of the anal region showing surrounding skin held apart with gloved hands and a red, irritated vertical area around the anus, indicating inflammation or injury for clinical or educational purposes.

Rationale: Although perineal irritation is abnormal, another finding takes precedence and should be reported immediately.

C.

Medical-style illustration of external male genital anatomy, showing the penis and scrotum in a simplified, neutral anatomical depiction for educational purposes.

Rationale: This uncircumcised penis does not display any abnormal findings that should be reported to the healthcare provider.

D.

Medical-style illustration of the anal region with gloved hands holding the surrounding skin apart, showing a small, localized lesion or inflamed area at the anal opening for clinical or educational reference.

Rationale: Although external hemorrhoids are abnormal, another finding takes precedence and should be reported immediately.

Want to learn more about this topic?

Watch the Osmosis video: Hygiene – Perineal care: Nursing skills

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