A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions.

Which of the following responses should the nurse make?

"You can apply counterpressure to your back with each position change."

"You can splint the incision with a pillow when changing positions."

"You should change positions as little as possible."

"You should use patterned-paced breathing when changing positions."

Answer and Explanation

The Correct Answer is B

Splinting the incision with a pillow when changing positions can provide support and help minimize discomfort and pain in clients who have undergone a cesarean birth. It can help reduce strain on the incision site and provide a sense of stability and comfort.

"You can apply counterpressure to your back with each position change" may be helpful for managing back pain, but it does not specifically address the client's request for nonpharmacological interventions to manage pain when changing positions after a cesarean birth.

"You should change positions as little as possible" is not an appropriate response as it does not address the client's need to manage pain when changing positions. Encouraging movement and position changes, along with appropriate support, can aid in recovery and prevent complications such as blood clots and respiratory issues.

"You should use patterned-paced breathing when changing positions" is not specifically related to managing pain when changing positions after a cesarean birth. While breathing techniques can be useful for pain management during labor and certain procedures, it may not be the most effective strategy for managing pain when changing positions post-cesarean.

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Correct Answer is C

Explanation

Explanation

C. Position the client on their left side

The symptoms of feeling dizzy, racing heart, and becoming pale while lying on their back are consistent with supine hypotensive syndrome or vena cava syndrome. This condition occurs when the pregnant uterus compresses the vena cava, reducing blood flow back to the heart and causing a drop-in blood pressure.

Positioning the client on their left side helps alleviate the pressure on the vena cava, allowing for improved blood flow and preventing further symptoms. This position optimizes blood circulation and reduces the risk of complications. The nurse should assist the client in turning onto their left side and ensure they are comfortable.

Providing the client with a glass of orange juice (option A) is not recommended as it may be helpful in cases of low blood sugar or hypoglycemia, but it is not the most appropriate action in this scenario.

Instructing the client to take a brisk walk (option B) is not recommended since physical exertion can further worsen the symptoms and increase the risk of complications.

Checking the client's temperature (option D) is not necessary as the reported symptoms are not indicative of a fever or infection.

Therefore, the most appropriate action for the nurse to take in this situation is to position the client on their left side (option C).

A. Chemotherapy treatments B. Medications for a cardiac anomaly C. Clear rhinorrhea D. Two diarrhea stools in the last day

Correct Answer is A

Explanation

Chemotherapy treatments, which are used to treat cancer, can suppress the immune system and weaken the body's ability to respond to vaccines. As a result, receiving a live attenuated vaccine like the varicella immunization can pose a risk of severe complications for individuals undergoing chemotherapy. Therefore, it is contraindicated to administer the varicella vaccine in this case.

Medications for a cardiac anomaly, clear rhinorrhea, and two diarrhea stools in the last day are not contraindications for receiving a varicella immunization.

While medications for a cardiac anomaly and certain medical conditions may require special consideration or precautions when administering vaccines, they are not absolute contraindications for the varicella vaccine. The decision to administer the vaccine would depend on the individual's specific circumstances and the healthcare provider's assessment. Clear rhinorrhea (runny nose) and two diarrhea stools in the last day are considered minor illnesses and do not contraindicate the varicella vaccine. Generally, mild illnesses without fever or systemic symptoms do not pose a significant risk when receiving vaccines. However, it is always important to assess the overall health status of the individual and consult with a healthcare provider if there are concerns.

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A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

Nursing Test Bank

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Correct Answer is C

Explanation

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A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions.

Which of the following responses should the nurse make?