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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Remove the patch for 8 hours every day to reduce the risk of tolerance.": This is incorrect. The fentanyl patch should be left in place continuously for the prescribed duration to maintain consistent pain relief and should not be removed unless instructed by a healthcare provider.
B. "Avoid hot tubs while wearing the patch.": This is an important instruction. Heat can increase the absorption of fentanyl from the patch, potentially leading to overdose. Therefore, avoiding hot tubs and other heat sources is crucial while using the patch.
C. "Avoid high-fiber foods while taking this medication.": This statement is not accurate. In fact, opioid medications like fentanyl often cause constipation, so high-fiber foods can be beneficial to help prevent this side effect.
D. "Apply the patch to your forearm.": This is not typically the recommended application site for fentanyl patches. They are usually applied to hairless areas of the upper body or upper outer arm, where they can adhere properly and be effective.
Correct Answer is A
Explanation
A) Determine if the client has thoughts about self-harm: In situations of acute grief and trauma, assessing for suicidal ideation is the priority. The nurse must ensure the client's safety first, as the loss of a partner in such a tragic circumstance can lead to overwhelming feelings of despair and hopelessness.
B) Review the client's available social support system: While understanding the client’s social support is important for ongoing care and coping strategies, it is not the immediate priority. Ensuring the client’s safety takes precedence over evaluating their support network.
C) Empower the client to feel that he is in charge of his life: Empowering the client is a valuable goal for long-term recovery, but it should come after assessing immediate safety and mental health needs. The client may not be in a state to feel empowered until basic concerns about their well-being are addressed.
D) Find the client a temporary shelter where he can feel safe: While finding shelter is crucial for the client’s physical safety and security, this action should follow the immediate assessment of the client’s mental health and any risk of self-harm. Ensuring psychological safety is the first step before addressing logistical needs.
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