A client had a laparoscopic bilateral tubal ligation (BTL) in the delivery room. Which intervention should a nurse plan to include in this client’s postoperative care?

Provide the client with an abdominal binder.

Provide a rocking chair at the client’s bedside.

Keep the head of the client’s bed flat for six hours.

Encourage the client to drink cold, carbonated fluids throughout the day.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D. Encourage the client to drink cold, carbonated fluids throughout the day.This helps to relieve the shoulder pain caused by the carbon dioxide gas used to inflate the abdomen during laparoscopy.

The gas irritates the diaphragm, which refers pain to the shoulder. Drinking cold, carbonated fluids can help expel the gas and reduce the pain.

Choice A is wrong because an abdominal binder is not necessary for a laparoscopic procedure. It is more commonly used for abdominal surgeries that involve a large incision.

Choice B is wrong because a rocking chair is not helpful for a client who had a laparoscopic BTL. It is more useful for a client who had a vaginal delivery to promote comfort and uterine involution.

Choice C is wrong because keeping the head of the bed flat for six hours is not indicated for a laparoscopic BTL. It may increase the risk of venous thromboembolism and pulmonary embolism due to prolonged immobility. The client should be encouraged to ambulate as soon as possible after surgery.

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Correct Answer is D

Explanation

The correct answer is choice D. Placing warmed tea bags on the nipples is not a recommended method to avoid nipple soreness while breastfeeding.Tea bags can cause dryness and cracking of the nipples, which can increase the risk of infection and pain.

Choice A is wrong because it is better to use both breasts at each feeding and switch the starting breast at each feeding.This helps to ensure adequate milk production and drainage.

Choice B is correct because rubbing breast milk into the nipple can help to moisturize and protect the nipple from infection.Breast milk has antibacterial and healing properties.

Choice C is correct because washing the nipples with water but no soap can help to prevent irritation and dryness of the nipples.

Soap can remove the natural oils that protect the skin.Letting the nipples air dry can also help to prevent fungal growth.

A. Ask the patient if she has had any alcoholic beverages within the past 24 hours. B. Find out if the patient has had any bloody vaginal discharge today. C. Tell the patient that the fetal heart rate does not appear to indicate that the baby is in distress. D. Explain to the patient the relationship between a woman's anxiety level and her ability to detect movement.

Correct Answer is C

Explanation

This is because a normal fetal heart rate is between 110 and 160 beats per minute, and the range of 136 to 143 indicates that the fetus is well-oxygenated and not experiencing hypoxia or acidosis. The nurse should reassure the patient and explain that fetal movement may decrease during labor due to the pressure of the contractions on the uterus and the fetus.

Choice A is wrong because asking the patient about alcohol consumption is irrelevant and insensitive.

Alcohol can affect fetal development and growth, but it does not directly affect fetal movement or heart rate.

Choice B is wrong because bloody vaginal discharge, or bloody show, is a normal sign of cervical dilation and effacement during labor.

It does not indicate fetal distress or placental abruption.

Choice D is wrong because explaining the relationship between anxiety and fetal movement does not address the patient’s concern or provide any factual information.

Anxiety can affect maternal perception of fetal movement, but it does not cause fetal movement to decrease.

The nurse should validate the patient’s feelings and provide factual reassurance.

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A client had a laparoscopic bilateral tubal ligation (BTL) in the delivery room. Which intervention should a nurse plan to include in this client’s postoperative care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse instructs a class of postpartum women on methods to avoid nipple soreness while breastfeeding. Which comment by a class participant indicates the need for further instruction?

Correct Answer is D

Explanation

A patient who is 42 weeks pregnant is admitted to the hospital in active labor.The patient is upset and says to the nurse, "I haven't felt the baby move for about three or four hours." The fetal heart rate is ranging between 136 and 143. Which action should the nurse take?

Correct Answer is C

Explanation

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