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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Explanation
Choice A Reason:
"I should empty my bladder before the procedure. "This statement indicate understanding of the teaching. Emptying the bladder before an amniocentesis is important to reduce the risk of accidental puncture during the procedure. A full bladder can obstruct the area where the needle is inserted, making it more difficult to perform the amniocentesis safely. Therefore, instructing the client to empty their bladder before the procedure is an essential part of pre-procedural preparation.
Choice B Reason:
"I should start fasting 24 hours before the procedure." This statement is incorrect. Fasting before an amniocentesis is not typically required. Amniocentesis is usually performed on an outpatient basis, and fasting is not necessary unless specifically instructed by the healthcare provider for a particular reason. Most healthcare providers recommend eating a light meal before the procedure to maintain energy levels and prevent hypoglycemia.
Choice C Reason:
"I will be asleep during the procedure." This statement is incorrect. Amniocentesis is usually performed while the client is awake. Local anesthesia may be administered to numb the skin and reduce discomfort during the procedure, but general anesthesia is not typically used. Clients are often instructed to remain still and relaxed during the procedure to minimize the risk of complications.
Choice D Reason:
"I will be lying on my side during the procedure." The client's position during an amniocentesis may vary depending on the healthcare provider's preference and the client's comfort. However, lying on the side is not a standard position for amniocentesis. The client may be asked to lie flat on their back or in a slightly reclined position to provide better access to the abdomen for the procedure.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.