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.
Position the client in reverse Trendelenburg.
Assist the client in the lithotomy position.
Place a wedge under one of the client’s hips.
The Correct Answer is D
This is because placing a wedge under one of the hips can help prevent compression of the inferior vena cava by the uterus, which can compromise placental blood flow and cause fetal hypoxia. Placing a wedge under the hip can also help reduce the risk of maternal hypotension, which can also affect fetal oxygenation.
Choice A is wrong because inserting a pillow under the client’s knees can increase the risk of thromboembolism, which is a potential complication of cesarean birth.
Choice B is wrong because positioning the client in reverse Trendelenburg can increase the risk of maternal aspiration, which is another potential complication of cesarean birth.
Choice C is wrong because assisting the client into the lithotomy position can also compress the inferior vena cava and reduce placental blood flow. The lithotomy position is also not necessary for cesarean birth, as the baby is delivered through an incision in the abdomen and uterus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is d. “Your desire to be an organ donor must be documented in writing.”
Rationale for Choice a:
- Statement:“Your name cannot be removed once you are listed on the organ donor list.”
- Rationale:This statement is incorrect.Individuals have the right to change their minds about organ donation at any time.They can have their names removed from the organ donor list by contacting the appropriate registry or organization.It's essential for nurses to provide accurate information to ensure informed consent and respect for patient autonomy.
Rationale for Choice b:
- Statement:“You must be at least 21 years of age to become an organ donor.”
- Rationale:This statement is also incorrect.The age requirement for organ donation varies by jurisdiction.In many places,individuals under 18 years of age can register as organ donors with parental consent.Nurses should be familiar with local regulations to provide accurate guidance.
Rationale for Choice c:
- Statement:“I cannot be a witness for your consent to donate.”
- Rationale:While it's true that nurses generally cannot act as witnesses for organ donation consent,the focus of the response should be on directing the client to the appropriate channels for documentation.Nurses can play a role in facilitating the process by providing information and resources to clients who express interest in organ donation.
Rationale for Choice d:
- Statement:“Your desire to be an organ donor must be documented in writing.”
- Rationale:This is the correct response.To ensure clarity and legal validity,organ donation preferences must be documented in writing.This documentation can be done through various means,such as registering with an organ donor registry,indicating preferences on a driver's license,or completing an advance directive.Nurses should emphasize the importance of written documentation to protect the client's wishes.
Correct Answer is C
Explanation
The correct answer is c. Remove the cap and place it sterile-side up on a clean surface.
Choice A rationale:
Placing sterile gauze over areas of spilled solution within the sterile field is incorrect. If solution is spilled within the sterile field, the entire field should be considered contaminated and a new sterile field should be set up
Choice B rationale:
Holding the irrigation solution bottle with the label facing away from the palm of the hand is incorrect. The label should face the palm of the hand to avoid contamination of the sterile field
Choice C rationale:
Removing the cap and placing it sterile-side up on a clean surface is correct. This ensures that the sterile side of the cap remains sterile and can be used to recap the bottle after pouring the solution
Choice D rationale:
Holding the bottle in the center of the sterile field when pouring the solution is incorrect. The bottle should be held over the edge of the sterile field to avoid contamination of the field if solution spills
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