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?

This is because the nurse should assess the client’s level of mobility, strength, and coordination before repositioning them to prevent injury and promote comfort. The nurse should also use appropriate assistive devices, such as a drawsheet, a trapeze bar, or a mechanical lift, to facilitate safe repositioning and reduce the risk of skin breakdown and pressure ulcers.

Choice A is wrong because raising the side rails on both sides of the client’s bed during repositioning can increase the risk of falls and entrapment.

The nurse should only raise the side rail on the opposite side of the bed from where they are working and lower it when they are done.

Choice B is wrong because repositioning the client without assistive devices can cause strain and injury to both the nurse and the client.

The nurse should use assistive devices that are appropriate for the client’s condition and weight.

Choice C is wrong because discussing the client’s preferences for determining a repositioning schedule is not a priority action when preparing to reposition a client who had a stroke.

The nurse should follow the facility’s protocol for repositioning frequency, which is usually every 2 hours, and adjust it according to the client’s needs and comfort.

The nurse should also involve the client in the care plan and respect their preferences whenever possible.

This is because boundaries can help the client and family to respect each other’s roles, needs, and preferences, and to avoid role confusion, resentment, or guilt. Boundaries can also promote independence and self-care for the client, as well as prevent caregiver burnout for the family.
Choice B is wrong because minimizing open discussion regarding the changes can lead to misunderstanding, frustration, or isolation. The client and family should communicate openly and honestly about their feelings, expectations, and challenges, and seek support when needed.
Choice C is wrong because authoritative communication from the adult child can create a power imbalance, undermine the client’s autonomy and dignity, or cause conflict or resistance. The client and family should use respectful and collaborative communication, and involve the client in decision-making as much as possible.
Choice D is wrong because decreasing socialization with extended relatives can reduce the client and family’s support network, increase their stress or loneliness, or limit their opportunities for meaningful activities. The client and family should maintain contact with their relatives and friends, and participate in social or recreational activities that they enjoy.