A nurse is providing discharge instructions to a client who is 3 days postoperative following a cesarean birth.
Which of the following statements from the client indicates that the teaching has been effective? (Select all that apply.)

“I will rest in a recliner until my incision is healed.”.

“I will call my provider if I have discharge from my incision.”.

“I will resume taking my prenatal vitamins.”.

“I should not have unrelieved pain in my abdomen.”.

Answer and Explanation

Correct Answer : B,C,D

Choice A rationale

Resting in a recliner until the incision is healed is not recommended following a cesarean birth. It’s important for the client to gradually increase their activities and mobility to promote healing and prevent complications such as blood clots.

Choice B rationale

It’s crucial for the client to monitor their incision for signs of infection, such as increased redness, swelling, pain, or discharge. Therefore, calling the provider if there is discharge from the incision indicates understanding of the discharge instructions.

Choice C rationale

Resuming prenatal vitamins is often recommended after a cesarean birth to aid in recovery and support breastfeeding if the client chooses to breastfeed. Prenatal vitamins contain essential nutrients that can help the client heal and recover after surgery.

Choice D rationale

Unrelieved abdominal pain is not a normal part of recovery and could indicate a complication such as an infection or a problem with the incision. Therefore, the client should understand that they should not have unrelieved pain in their abdomen and should contact their provider if they do.

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Correct Answer is C

Explanation

Hypoglycemia, or low blood sugar, is a common condition in newborns, especially those born to mothers with diabetes, those who are small for their gestational age, or those who have been stressed during birth. It’s important to monitor the newborn’s serum glucose level and report any abnormalities to the healthcare provider.

A. Turn the client onto her side. B. Increase the client’s IV fluid infusion rate. C. Palpate the client’s uterus. D. Administer oxygen to the client.

Correct Answer is A

Explanation

Choice A rationale

Turning the client onto her side is the first action the nurse should take when late decelerations are noted on the fetal monitor. Late decelerations can indicate uteroplacental insufficiency, and turning the client onto her side can improve placental blood flow and oxygen delivery to the fetus.

Choice B rationale

Increasing the client’s IV fluid infusion rate can help increase maternal blood volume and improve placental perfusion. However, it is not the first action to take when late decelerations are noted.

Choice C rationale

Palpating the client’s uterus can provide information about the strength, duration, and frequency of contractions, but it is not the first action to take when late decelerations are noted.

Choice D rationale

Administering oxygen to the client can increase the amount of available oxygen for fetal oxygenation. However, it is not the first action to take when late decelerations are noted.

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A nurse is providing discharge instructions to a client who is 3 days postoperative following a cesarean birth. Which of the following statements from the client indicates that the teaching has been effective? (Select all that apply.)

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is attending to a newborn 2 hours after birth. Which four observations should the nurse report to the healthcare provider?

Correct Answer is C

Explanation

A nurse is caring for a client who is in active labor when the client’s membranes rupture. The fetal monitor tracing shows late decelerations. What is the first action the nurse should take?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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A nurse is providing discharge instructions to a client who is 3 days postoperative following a cesarean birth.
Which of the following statements from the client indicates that the teaching has been effective? (Select all that apply.)