A nurse is assessing for pain for a client following a cesarean birth 24 hr ago. Which of the following questions should the nurse ask to determine if a PRN pain medication is indicated?

"Have you noticed any swelling in your feet?"

"Do you have any leakage from your incision?"

"Do you notice increased cramping with breastfeeding?"

"Are you able to pass gas?"

Answer and Explanation

The Correct Answer is C

Explanation

Choice A Reason:

"Have you noticed any swelling in your feet?" This question is inappropriate. Swelling in the feet is not directly related to postoperative pain following a cesarean birth. While swelling may indicate other issues such as fluid retention, it is not typically a primary indicator of pain requiring PRN pain medication.

Choice B Reason:

"Do you have any leakage from your incision?" This question is inappropriate. Leakage from the incision may indicate wound complications such as infection or dehiscence, but it does not specifically assess pain. PRN pain medication would be indicated based on the client's reported pain level, rather than the presence of incisional leakage alone.

Choice C Reason:

"Do you notice increased cramping with breastfeeding?" This question is appropriate. After a cesarean birth, it is common for women to experience cramping, especially during breastfeeding. This is due to the release of oxytocin, a hormone that helps the uterus contract back to its pre-pregnancy size. Increased cramping with breastfeeding can exacerbate postoperative pain in women who have undergone a cesarean birth. Therefore, asking about increased cramping with breastfeeding is an important question to assess pain and determine if additional pain medication is needed.

Choice D Reason:

"Are you able to pass gas?" This question is inappropriate. Passing gas is an important aspect of gastrointestinal function but is not directly related to postoperative pain following a cesarean birth. While constipation and gastrointestinal issues can contribute to discomfort, asking about the ability to pass gas does not specifically assess pain or indicate the need for PRN pain medication.

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Correct Answer is A,B,C,D,E

Explanation

Choice A Reason:

Applying a warm cloth to the newborn's heel helps dilate the blood vessels, making it easier to obtain a blood sample by increasing blood flow to the area. This can improve the likelihood of a successful blood draw and minimize discomfort for the newborn.

Choice B Reason:

Cleaning the area with an antiseptic, such as alcohol or iodine solution, helps reduce the risk of introducing bacteria or other contaminants into the puncture site. This step is essential for preventing infection and ensuring the safety of the procedure.

Choice C Reason:

Puncturing the outer aspect of the newborn's heel with a lancet or other sterile device allows access to capillary blood vessels, from which a blood sample can be obtained. This step should be performed quickly and accurately to minimize discomfort and trauma to the newborn.

Choice D Reason:

After puncturing the newborn's heel, blood will start to flow from the capillaries. The nurse should collect the necessary amount of blood into a collection device, such as a microtainer or capillary tube, for laboratory analysis. It's important to ensure proper labeling of the specimen to prevent mix-ups.

Choice E Reason:

After obtaining the blood sample, applying pressure to the puncture site with a dry gauze pad helps promote clotting and minimize bleeding. This step is crucial for preventing excessive bleeding and ensuring the newborn's comfort. The pressure should be applied for an adequate amount of time to allow the blood to clot effectively.

A. Cover the umbilical cord with a sterile saline saturated towel. B. Administer oxygen via nonrebreather mask at 8 L/min. C. Perform a vaginal examination by applying upward pressure on the presenting part. D. Initiate an infusion of IV fluids for the client.

Correct Answer is C

Explanation

Choice A Reason:

Covering the exposed umbilical cord with a sterile saline-saturated towel is an appropriate intervention to prevent the cord from drying out and to reduce the risk of infection. However, this is not the most immediate action that should be taken. The priority is to relieve pressure on the umbilical cord to restore blood flow to the fetus, which is more urgent than covering the cord.

Choice B Reason:

Administering oxygen can help improve maternal oxygenation, which in turn can benefit the fetus. However, in this situation, the immediate priority is to relieve the pressure on the umbilical cord to prevent fetal hypoxia. Administering oxygen is important but secondary to the mechanical relief of cord compression.

Choice C Reason:

This is the most critical and immediate action. Applying upward pressure on the presenting part (e.g., the fetal head) can relieve pressure on the umbilical cord, which is crucial to restore blood flow to the fetus and prevent fetal hypoxia and bradycardia. This action directly addresses the life-threatening situation posed by a prolapsed umbilical cord.

Choice D Reason:

Initiating IV fluids can help maintain maternal blood pressure and support fetal circulation. However, this intervention is not as immediate or directly life-saving as relieving the pressure on the umbilical cord. It can be done after the more urgent interventions are initiated.

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A nurse is assessing for pain for a client following a cesarean birth 24 hr ago. Which of the following questions should the nurse ask to determine if a PRN pain medication is indicated?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to obtain a blood sample from a newborn's heel. In what order should the nurse perform the procedure? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is A,B,C,D,E

Explanation

A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following actions should the nurse take next?

Correct Answer is C

Explanation

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