A nurse is planning care for a client who is scheduled for a cesarean birth.
Which of the following interventions should the nurse include in the plan of care?

Apply sequential compression devices prior to the procedure.

Insert an indwelling urinary catheter immediately following the procedure.

Initiate oxytocin via continuous IV infusion prior to the procedure.

Perform a surgical timeout while the client is in the preoperative holding area.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Sequential compression devices (SCDs) are applied preoperatively to promote venous return and prevent venous stasis in the lower extremities, significantly reducing the risk of deep vein thrombosis (DVT) and subsequent pulmonary embolism (PE), which are critical concerns during and after major surgery like a cesarean birth. Prophylaxis should commence before the operation for maximal effect.

Choice B rationale

An indwelling urinary catheter is typically inserted prior to the cesarean section, after the client receives regional anesthesia, to ensure the bladder is empty during the procedure, preventing injury to the bladder by the surgeon and maintaining a clear surgical field. It is not delayed until immediately following the procedure.

Choice C rationale

Oxytocin is a uterotonic agent administered post-delivery of the placenta (not prior to the procedure) via continuous IV infusion to stimulate uterine contractions, which is crucial for preventing postpartum hemorrhage by promoting myometrial contraction and vessel constriction.

Choice D rationale

The surgical timeout, a critical patient safety measure that verifies the correct patient, procedure, and surgical site, is performed by the entire surgical team immediately prior to the incision, typically after the client enters the operating room and is prepped, not while they are in the preoperative holding area.

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Correct Answer is D

Explanation

Choice A rationale

Skin mottling, characterized by a patchy, net-like, reddish-blue discoloration of the skin, is typically caused by vasoconstriction in response to cold exposure or by circulatory changes in individuals with poor peripheral perfusion. This is not a typical, expected body change during a normal pregnancy; expected skin changes relate more to hyperpigmentation (e.g., chloasma, linea nigra).

Choice B rationale

During pregnancy, hormonal changes, particularly the increase in estrogen, shift a greater proportion of hair follicles into the anagen (growth) phase, leading to thicker, fuller hair. Hair thinning (telogen effluvium) is commonly experienced postpartum when hormone levels drop and the hair follicles shift rapidly back into the telogen (resting) phase, thus it is not expected at 14 weeks gestation.

Choice C rationale

Nipple inversion is a structural variation where the nipple is retracted into the areola; it is not a change that typically develops during pregnancy. Expected breast changes include areolar darkening (hyperpigmentation), prominent Montgomery's tubercles, and nipple erection. Nipple inversion is a pre-existing condition that may present challenges for breastfeeding.

Choice D rationale

Breast enlargement (hypertrophy) is an expected and early body change during pregnancy, beginning in the first trimester (around 6 weeks). This growth is driven by elevated estrogen and progesterone levels, stimulating the development of the mammary glands in preparation for lactation, and is often accompanied by tenderness and increased vascularity.

A. Give an IM injection of methylergonovine. B. Administer oxygen at 2 L/min via nasal cannula. C. Start an IV bolus of dextrose 5% in water. D. Assist the client to a knee-chest position.

Correct Answer is A

Explanation

Choice A rationale

Methylergonovine is an uterotonic agent that acts on the smooth muscle of the uterus to stimulate strong, sustained contractions, which are essential for compressing the intramyometrial blood vessels and achieving hemostasis to stop postpartum hemorrhage, especially from uterine atony.

Choice B rationale

While oxygen is important for hypoxia secondary to blood loss, administering it at 2 L/min via nasal cannula is typically insufficient for a client experiencing significant hemorrhage. High-flow oxygen, such as 10 to 15 L/min via nonrebreather mask, is usually required to maximize oxygen saturation.

Choice C rationale

Starting an IV bolus of Dextrose 5.

Choice D rationale

The knee-chest position is generally used to relieve cord compression or help with the manual rotation of the fetus, but it is not an established intervention for managing postpartum hemorrhage. The client should be positioned flat with legs elevated to promote venous return and manage shock.

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A nurse is planning care for a client who is scheduled for a cesarean birth. Which of the following interventions should the nurse include in the plan of care?

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A nurse is planning care for a client who is scheduled for a cesarean birth.
Which of the following interventions should the nurse include in the plan of care?