A nurse is reinforcing preoperative teaching with a client who is scheduled for a cesarean birth. Which of the following client statements indicates an understanding of the teaching?
"The nurse will take out my urinary catheter 48 hours after surgery."
"The nurse might need to massage my uterus frequently after surgery."
"I can have regular food once I am able to swallow safely."
"I will need to stay flat on my back in bed for the first 24 hours after surgery."
The Correct Answer is B
A. The urinary catheter is usually removed within the first 24 hours after a cesarean birth, not 48 hours. Early removal helps prevent complications and promotes recovery.
B. Uterine massage is performed to prevent postpartum hemorrhage and ensure the uterus is contracting properly. This practice is part of standard postpartum care to promote uterine involution.
C. Postoperative diet progression typically starts with clear liquids and advances as tolerated. Regular food is introduced once the client can swallow safely and shows no signs of nausea or gastrointestinal issues.
D. Staying flat on the back is not required post-cesarean section. Early ambulation is encouraged to prevent complications like deep vein thrombosis and to promote healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
- Potential Condition: Endometritis. The symptoms of malaise, chills, decreased appetite, elevated temperature, tachycardia, a boggy and tender uterus, and foul-smelling lochia are indicative of a postpartum infection, such as endometritis.
- Actions to Take:
- Monitor the lochia amount and odor: This will help assess the presence of infection and the effectiveness of treatment.
- Assist with the administration of prescribed antibiotics: Antibiotics are the primary treatment for endometritis.
- Parameters to Monitor:
- Temperature: Monitoring for fever can help assess the response to treatment and indicate if the infection is resolving or worsening.
- Heart rate: Tachycardia may be a sign of infection or other complications, so it's important to monitor changes in heart rate.
Correct Answer is A
Explanation
A. The lecithin/sphingomyelin (L/S) ratio assesses fetal lung maturity. A higher ratio indicates that the baby's lungs are mature enough to handle breathing air outside the womb, which is the primary purpose of this test.
B. The L/S ratio test does not assess placental function. Placental function is evaluated through other tests, such as Doppler studies or biophysical profiles.
C. The L/S ratio test is not related to Rh incompatibility. Rh incompatibility issues are managed through different assessments, such as the Coombs test and Rh factor screening.
D. The L/S ratio test does not indicate genetic disorders. Genetic disorders are assessed through tests like amniocentesis or chorionic villus sampling, not the L/S ratio.
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