A nurse is caring for a client who had an unscheduled cesarean delivery due to fetal distress.
Which of the following interventions should the nurse implement in the immediate postoperative period?
Assess the client’s fundus for firmness and position
Encourage early ambulation to prevent thromboembolism
Monitor the client’s intake and output
All of the above.
The Correct Answer is A
The correct answer is choice D. All of the above interventions should be implemented in the immediate postoperative period after a cesarean delivery.
Choice A is correct because assessing the client’s fundus for firmness and position is important to prevent postpartum hemorrhage and monitor uterine involution. The fundus should be firm and at the level of the umbilicus one hour after delivery and descend into the pelvis at a rate of approximately 1 cm per day.
Choice B is correct because encouraging early ambulation can prevent thromboembolism, which is a potential complication of cesarean delivery. Early mobilization can also reduce pain, ileus, and urinary retention.
Choice C is correct because monitoring the client’s intake and output can help detect fluid imbalance, dehydration, or urinary tract infection.
Fluid intake should be adequate to maintain hydration and support lactation. Urinary output should be at least 30 mL per hour.
Therefore, choice D is correct because all of the above interventions are appropriate for postoperative care after a cesarean delivery.
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Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. The client can use patient-controlled analgesia to self-administer opioids.This is a form of multimodal analgesia, which is the core principle for cesarean delivery pain management.
Patient-controlled analgesia allows the client to have control over their pain relief and adjust the dose according to their needs.
Choice A is wrong because the client may experience delays in receiving analgesics if they have to request them from the nurse, which can lead to inadequate pain relief and increased opioid consumption.
Choice C is wrong because ice packs are not recommended for cesarean delivery pain management, as they may interfere with wound healing and increase the risk of infection.
Choice D is wrong because deep breathing and relaxation exercises are not sufficient to manage acute postoperative pain, although they may be helpful as adjuncts to pharmacologic methods.
Correct Answer is D
Explanation
The correct answer is choiceD) Use of incentive spirometry.Incentive spirometry is a device that helps patients take slow, deep breaths to expand their lungs and prevent respiratory complications such as pneumonia and atelectasis.Incentive spirometry also helps clear mucus and fluids from the lungs and improves ventilation.
Choice A is wrong because controlling anxiety and agitation may not directly prevent respiratory complications, although it may help patients breathe more comfortably.
Choice B is wrong because adequate nutrition and fluids are important for general health and recovery, but they do not specifically prevent respiratory complications.
Choice C is wrong because adequate pain control may help patients breathe more deeply and cough more effectively, but it is not enough to prevent respiratory complications by itself.
Choice E is wrong because early ambulation may improve blood circulation and reduce the risk of thromboembolism, but it does not directly prevent respiratory complications.
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