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?"
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Explanation
Choice A Reason:
Immediate cesarean birth is not typically indicated for IUFD unless there are specific maternal or fetal complications that necessitate urgent delivery. In most cases, scheduled induction of labor is preferred over immediate cesarean birth.
Choice B Reason:
Scheduled induction of labor is correct. In cases of intrauterine fetal demise (IUFD), the provider will typically discuss options for the management of the pregnancy. Scheduled induction of labor is a common approach to manage IUFD in order to deliver the fetus and prevent potential complications associated with a prolonged retention of the nonviable fetus in the uterus. This allows for the prompt initiation of the grieving process for the parents and reduces the risk of maternal complications such as infection or disseminated intravascular coagulation (DIC).
Choice C Reason:
Dilation with suction curettage is incorrect. Dilation and suction curettage may be considered for managing IUFD in cases where induction of labor is not feasible or appropriate. However, it is not typically the first-line treatment option, especially at 36 weeks of gestation when labor induction is a safe and effective option.
Choice D Reason:
Administration of methotrexate is incorrect. Methotrexate is a medication used for medical management of ectopic pregnancy or in cases of fetal demise in early pregnancy. However, it is not typically used for IUFD at 36 weeks of gestation. Methotrexate administration is generally reserved for early gestational ages and may not be effective or appropriate for managing IUFD at this stage of pregnancy.
Correct Answer is C
Explanation
Explanation
Choice A Reason:
"Do your contractions feel further apart?" This question does not directly assess the effectiveness of the hands-and-knees position in rotating the baby or relieving discomfort associated with occipitoposterior position. It focuses on the timing of contractions rather than the impact of the position change.
Choice B Reason:
"Are you feeling relief from your pelvic pressure?" Pelvic pressure is more associated with the descending fetus and the overall labor process. The hands-and-knees position is mainly intended to alleviate back pain caused by the fetus's occipitoposterior position, rather than pelvic pressure.
Choice C Reason:
"Has your back labor improved?" The hands-and-knees position is often used to help alleviate back labor, a common issue with a fetus in the occipitoposterior position. The pressure from the fetal head on the mother's spine can cause significant back pain, and the hands-and-knees position can help by shifting the fetal position slightly and relieving some of this discomfort.
Choice D Reason:
"Does that lessen your suprapubic pain?" Suprapubic pain is more related to the pressure of the descending fetus on the bladder and the lower uterus. While the hands-and-knees position may alleviate some discomfort, it is primarily aimed at relieving back labor caused by the occipitoposterior position, not suprapubic pain.
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