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.

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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Correct Answer is C

Explanation

A. HSV-2 can cause neonatal herpes, which may result in serious complications or fetal demise if transmitted at delivery.
B. Tight-fitting undergarments can increase moisture and irritation; clients should wear loose cotton underwear to promote healing.
C. The risk of neonatal transmission is highest when active lesions or viral shedding are present at the time of vaginal delivery.
D. Antiviral medications (e.g., acyclovir) suppress viral replication and reduce outbreaks and shedding but do not eradicate the virus.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Hyperbilirubinemia is a concern due to the presence of cephalohematoma (a firm, edematous area on the scalp that does not cross suture lines) and yellow sclera, both of which are indicators of increased bilirubin from red blood cell breakdown.
The head assessment reveals these findings (scleral icterus and cephalohematoma), which directly support the risk.

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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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Naxlex Comprehensive Predictor Exams

A nurse is providing teaching with an antepartum client who has a new diagnosis of genital herpes simplex virus 2 (HSV-2). Which of the following information should the nurse include?

Correct Answer is C

Explanation

A nurse is caring for a newborn Exhibits Complete the sentence below using the list of options The newborn is at highest risk of developing dropdown as evidenced by the newborn’s Blank 2 dropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

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