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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A and it indicates fetal distress because it is a sign oflate deceleration.Late decelerations are due touteroplacental insufficiencyas the result of decreased blood flow and oxygen to the fetus during the uterine contractions.This causeshypoxemiaand can lead to fetal acidosis and neurological damage.
Choice B is wrong because it indicates anormal variabilityin the fetal heart rate, which reflects a healthy autonomic nervous system.A normal fetal heart rate is 120-160 beats per minute.
Choice C is wrong because it indicates anearly accelerationin the fetal heart rate, which is a benign finding that may occur with fetal movement or stimulation.
Choice D is wrong because it indicates anearly decelerationin the fetal heart rate, which is a normal response to fetal head compression during contractions.
It does not indicate fetal distress.
Normal ranges for fetal heart rate patterns are:
• Baseline: 120-160 beats per minute
• Variability: 6-25 beats per minute
• Accelerations: at least 15 beats per minute above baseline for at least 15 seconds
• Decelerations: none or early (mirror contractions)
Correct Answer is B
Explanation
Physiologic jaundice is a common condition in newborns that occurs when the baby’s blood contains an excess of bilirubin, a yellow pigment produced during the normal breakdown of red blood cells.In the womb, the mother’s liver removes bilirubin for the baby, but after birth the baby’s own liver must take over this function.Because the baby has more red blood cells than an adult and their liver is still immature, they may not be able to process all the bilirubin and it may build up in their skin and eyes, causing a yellowish appearance.
Choice A is wrong because it is not an increase in neonatal metabolism that causes physiologic jaundice, but rather a decrease in hepatic metabolism of bilirubin.
Choice C is wrong because it describes a different type of jaundice called hemolytic jaundice, which occurs when there is an incompatibility between the blood types of the mother and the baby, leading to an immune reaction that destroys the baby’s red blood cells faster than they can be replaced.
Choice D is wrong because it confuses the reticuloendothelial system with the hepatic system.
The reticuloendothelial system is a network of cells and tissues that are involved in immune responses and phagocytosis (the ingestion of foreign particles or cells).
The hepatic system is the system of organs and structures that are involved in liver functions, such as bile production and detoxification.
Normal ranges for bilirubin levels in newborns are 1 to 12 mg/dL (17 to 205 micromol/L) for total bilirubin and 0.2 to 1.4 mg/dL (3 to 24 micromol/L) for direct bilirubin.
Physiologic jaundice usually peaks at 3 to 5 days after birth and resolves by 2 weeks of age.
It does not require treatment unless the bilirubin levels are very high or rising rapidly, which may indicate a more serious condition or a risk of brain damage.
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