A nurse is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take?

Insert a pillow under the client's knees.

Assist the client into the lithotomy position,

Place a wedge under one of the client's hips.

Position the client in reverse Trendelenburg.

Answer and Explanation

The Correct Answer is C

A) Insert a pillow under the client's knees: While placing a pillow under the knees may promote comfort, it can lead to increased pressure on the lower back and may not effectively address potential compression of the vena cava, which is crucial in maintaining optimal placental blood flow during surgery.

B) Assist the client into the lithotomy position: The lithotomy position can increase pressure on the abdominal vessels, potentially compromising blood flow to the placenta. This position should be used cautiously, especially in clients with concerns regarding blood flow.

C) Place a wedge under one of the client's hips: This action is appropriate as it helps to displace the uterus laterally, reducing pressure on the inferior vena cava. This maneuver improves venous return and maintains placental perfusion, which is critical during cesarean delivery.

D) Position the client in reverse Trendelenburg: Although this position elevates the upper body, it does not specifically address the potential for vena cava compression caused by the weight of the uterus. It is less effective than placing a wedge under the hips in terms of preserving placental blood flow.

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Correct Answer is D

Explanation

A) Rotate health care staff caring for the client: While having a variety of staff can provide different perspectives, it may not be the best approach for immunosuppressed clients. Consistency in care is often more beneficial, as it helps to minimize exposure to different pathogens.

B) Monitor the client's vital signs every 12 hr: Monitoring vital signs is important, but for clients with immunosuppression, more frequent monitoring is often necessary. This can help detect early signs of infection or complications that may arise more rapidly in this population.

C) Provide fresh fruit with the client's meals: Fresh fruits can pose a risk of bacterial contamination, particularly for immunosuppressed clients. It is generally safer to provide cooked fruits or fruit that has been properly washed and peeled to minimize this risk.

D) Inspect the client's mouth every 8 hr: Regular oral assessments are crucial for clients experiencing immunosuppression, as they are at a higher risk for oral infections and mucositis. This intervention allows for early detection and management of any abnormalities, thus promoting better overall health.

A. Obtain a trough level 30 min after the medication infusion. B. Inject 1% lidocaine prior to each dose. C. Give the dose over 60 min. D. Administer the medication undiluted.

Correct Answer is C

Explanation

A. Obtain a trough level 30 min after the medication infusion: Trough levels should be drawn just before the next dose, not 30 minutes after the infusion. This timing ensures accurate measurement of the drug’s lowest concentration in the bloodstream.

B. Inject 1% lidocaine prior to each dose: While lidocaine may help reduce discomfort at the injection site, it is not a standard practice for all patients receiving vancomycin and does not address the risk of systemic adverse reactions.

C. Give the dose over 60 min: Administering vancomycin over a period of at least 60 minutes is essential to minimize the risk of infusion-related reactions, such as "red man syndrome," which can occur if the drug is infused too quickly.

D. Administer the medication undiluted: Vancomycin should always be diluted according to guidelines before administration to reduce the risk of irritation to the veins and potential adverse reactions. Administering undiluted increases the risk of complications.

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A nurse is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take?

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