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?
Insert an indwelling urinary catheter immediately following the procedure.
Apply sequential compression devices prior to the procedure.
Perform a surgical timeout while the client is in the preoperative holding area.
Initiate oxytocin via continuous IV infusion prior to the procedure.
The Correct Answer is B
A. An indwelling urinary catheter is typically inserted before surgery, not immediately after, to keep the bladder empty during the procedure.
B. Applying sequential compression devices prior to the procedure is a key intervention to prevent deep vein thrombosis, which is a high-risk complication for clients undergoing cesarean birth.
C. Performing a surgical timeout is important but is a standard surgical protocol rather than a nursing-specific intervention for cesarean birth preparation.
D. Oxytocin is administered after delivery of the placenta to promote uterine contraction and prevent postpartum hemorrhage, not before surgery.
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Related Questions
Correct Answer is A
Explanation
A. The diaphragm should be inserted after emptying the bladder to reduce the risk of urinary tract infections.
B. Baby powder should not be applied to the diaphragm as it can cause irritation or damage.
C. Oil-based lubricants can degrade latex diaphragms and reduce their effectiveness; only water-based lubricants should be used.
D. The diaphragm should be left in place for at least 6 hours after intercourse, not just 4 hours, to ensure effective contraception.
Correct Answer is D
Explanation
A. The electronic monitoring band should remain on the newborn at all times to ensure security.
B. While visitor limitations may be advised during outbreaks or pandemics, this is not a standard newborn security measure.
C. Sending the newborn to the nursery unsupervised increases the risk of abduction and is not recommended.
D. Parents should be encouraged to verify staff identification to enhance newborn security and safety.
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