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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?

A.

Insert an indwelling urinary catheter immediately following the procedure.

B.

Apply sequential compression devices prior to the procedure.

C.

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

D.

Initiate oxytocin via continuous IV infusion prior to the procedure.

Answer and Explanation

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 B

Explanation

A. Irrigating the insertion site with sterile water is not a standard part of the procedure.
B. Rh-negative clients are at risk for isoimmunization if fetal blood mixes with maternal blood during the procedure. Rh(D) immune globulin should be administered after the procedure to prevent Rh sensitization.
C. The client is usually positioned supine with a slight tilt to prevent vena cava compression, not strictly in a left lateral position.
D. Amniocentesis does not require the client to be NPO.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"A"},"H":{"answers":"B"}}

Explanation

Statement

Include

Not Include

"Your baby needs to be repositioned every 2 to 3 hours while under the lights."

✅

"Your baby's eyes will be covered with an eye shield during therapy."

✅

"Avoid applying lotion to your baby's skin."

✅

"Keep a hat on your baby during treatment."

✅

"We will give your baby glucose water between breast feedings.

✅

"Bilirubin is primarily excreted through the stool."

✅

The treatment lights can cause a transient skin rash on your baby."

✅

The treatment lights emit a significant amount of ultraviolet radiation.

✅

  • Repositioning every 2 to 3 hours exposes different skin areas to light, enhancing bilirubin breakdown and preventing pressure sores.
  • Eye shields protect the newborn’s eyes from damage caused by bright phototherapy lights.
  • Avoiding lotion prevents skin irritation or burns and ensures effective light penetration during treatment.
  • Keeping a hat on blocks light exposure to the scalp, reducing the effectiveness of phototherapy.
  • Glucose water is not recommended; feeding with breast milk or formula helps promote bilirubin elimination through stools.
  • Bilirubin is mainly excreted through the stool after being converted into a water-soluble form by phototherapy.
  • Phototherapy can cause a mild, temporary rash, which is harmless but important to inform parents about.
  • Phototherapy lights emit blue light, not harmful ultraviolet radiation, making them safe for newborn treatment.

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