A nurse is caring for a client following a cesarean birth. The client tells the nurse that she is hungry. Which of the following actions should the nurse take first?
Offer clear liquids.
Auscultate the client's abdomen.
Check the client's chart for a diet prescription.
Give the client soda crackers.
The Correct Answer is B
Choice B reason:
Auscultating the client's abdomen is the first action the nurse should take, as it can assess the return of bowel function after surgery. The nurse should listen for bowel sounds in all four quadrants, and note their frequency and quality.
Offering clear liquids is an important action, as it can provide hydration and nutrition for the client. However, this is not the first action the nurse should take, as it may cause nausea and vomiting if the client's bowel function has not returned.
Choice C reason:
Checking the client's chart for a diet prescription is an important action, as it can ensure that the client follows the provider's orders and does not consume anything contraindicated. However, this is not the first action the nurse should take, as it does not address the client's hunger or bowel function.
Choice D reason:
Giving the client soda crackers is an important action, as it can provide a bland and easily digestible food for the client. However, this is not the first action the nurse should take, as it may be too solid for the client's stomach if her bowel function has not returned.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm above the ischial spines is incorrect, as this does not follow the correct order and measurement of cervical assessment. Cervical effacement is measured in percentage, not in centimeters, and it indicates the thinning or shortening of the cervix. Cervical dilation is measured in centimeters, not in percentage, and it indicates the opening or widening of the cervix.
Choice B reason: The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm above the ischial spines is correct, as this follows the correct order and measurement of cervical assessment. Cervical dilation, effacement, and station are recorded in that order to describe the progress of labor. Station refers to the relationship between the presenting part of the fetus and the maternal pelvis, measured by the level of the ischial spines. A negative station means that the presenting part is above the spines, while a positive station means that it is below.
Choice C reason: The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm below the ischial spines is incorrect, as this does not follow the correct order and measurement of cervical assessment. Cervical effacement is measured in percentage, not in centimeters, and it indicates the thinning or shortening of the cervix. Cervical dilation is measured in centimeters, not in percentage, and it indicates the opening or widening of the cervix.
Choice D reason: The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm below the ischial spines is incorrect, as this does not match the documentation of station. A negative station means that the presenting part is above the spines, while a positive station means that it is below.
Correct Answer is B
Explanation
Choice A reason: Perform fundal massage is incorrect, as this action is not indicated for a client who has a firm and midline fundus. Fundal massage is used to stimulate uterine contraction and prevent hemorrhage in clients who have a boggy or deviated fundus.
Choice B reason: Assist the client to ambulate is correct, as this action can promote lochia drainage and prevent pooling of blood in the vagina. The nurse should encourage the client to ambulate early and frequently after birth, as long as there are no contraindications. The nurse should also monitor the client for signs of orthostatic hypotension and provide assistance as needed.
Choice C reason: Check for blood under the client's butock is incorrect, as this action is not necessary for a client who has a small amount of lochia rubra on the perineal pad. Lochia rubra is normal and expected in the first few days after birth, and it indicates that the placental site is healing. The nurse should check for blood under the butock only if there is suspicion of excessive bleeding or concealed hemorrhage.
Choice D reason: Increase the rate of the IV fluids is incorrect, as this action is not indicated for a client who has a small amount of lochia rubra on the perineal pad. Increasing the rate of IV fluids can cause fluid overload and electrolyte imbalance in the client. The nurse should maintain the IV fluids at the prescribed rate and monitor the client's intake and output.
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