A nurse is teaching a class to clients who are pregnant.
Which of the following topics should the nurse include in the discussion about cesarean birth? (Select all that apply.)
Routine use of intubation equipment during birth.
Delay in initiating breastfeeding.
Advantage of early ambulation post-surgical procedure.
Management of postpartum pain.
The need for an indwelling urinary catheter.
Correct Answer : C,D,E
Choice A rationale
Routine use of intubation equipment during a cesarean birth is not standard practice. Intubation is typically reserved for general anesthesia or respiratory compromise. Most cesarean births are performed under regional anesthesia, such as a spinal or epidural block, which allows the mother to remain awake and avoid the need for invasive airway management, minimizing associated risks.
Choice B rationale
Delay in initiating breastfeeding after a cesarean birth is not a universal or recommended practice. While there may be a slight delay due to recovery from anesthesia, early skin-to-skin contact and breastfeeding are encouraged as soon as the mother is stable and alert. This promotes maternal-infant bonding and successful lactation establishment, supporting newborn nutrition and development.
Choice C rationale
Early ambulation post-surgical procedure, including cesarean birth, is highly advantageous for preventing complications such as deep vein thrombosis and promoting recovery. Movement stimulates circulation, reduces gas accumulation in the intestines, and aids in the restoration of normal bowel function. This active recovery approach significantly improves patient outcomes and comfort.
Choice D rationale
Management of postpartum pain is a critical topic for clients undergoing a cesarean birth. Effective pain control is essential for the mother's comfort, ability to ambulate, and capacity to care for her newborn. Education should cover various pharmacological and non-pharmacological pain relief methods, including medication schedules, side effects, and when to request additional pain relief.
Choice E rationale
The need for an indwelling urinary catheter is a common aspect of cesarean birth. A catheter is typically inserted before the procedure to keep the bladder empty, reducing the risk of bladder injury during surgery and allowing for accurate monitoring of urine output post-operatively. It is usually removed within 12 to 24 hours postpartum as ambulation is initiated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A positive phenylketonuria (PKU) test indicates an inability to metabolize the amino acid phenylalanine, not galactose. Galactosemia is a separate metabolic disorder characterized by the body's inability to break down galactose, a sugar found in milk. Both are inborn errors of metabolism, but their biochemical pathways and dietary interventions differ significantly.
Choice B rationale
A positive PKU test does not indicate a slow metabolism in general. Instead, it specifically points to a deficiency in the enzyme phenylalanine hydroxylase (PAH), which is necessary for converting phenylalanine into tyrosine. This enzymatic defect leads to an accumulation of phenylalanine in the blood and tissues, which can become neurotoxic if untreated.
Choice C rationale
A positive finding for phenylketonuria (PKU) signifies a genetic disorder where the body lacks or has insufficient amounts of the enzyme phenylalanine hydroxylase. This enzyme is crucial for metabolizing the essential amino acid phenylalanine into tyrosine. Without proper enzyme function, phenylalanine accumulates in the blood, leading to neurotoxic effects if a specialized diet is not initiated promptly.
Choice D rationale
A positive PKU finding, if left untreated, directly leads to severe intellectual disability and other neurological problems due to the accumulation of phenylalanine, which is toxic to the developing brain. Therefore, it indicates an increased risk for neurologic anomalies if the condition is not managed through a strict low-phenylalanine diet from early infancy. .
Correct Answer is D
Explanation
Choice A rationale
A respiratory rate of 34 breaths/min for a newborn is within the normal physiological range, which is typically 30 to 60 breaths/min. This finding does not indicate an immediate respiratory compromise or distress, and thus, this newborn does not require the most urgent assessment compared to others.
Choice B rationale
Acrocyanosis, which is the bluish discoloration of the hands and feet, is a common and usually benign finding in newborns during the first 24 to 48 hours after birth. It is due to immature peripheral circulation and does not indicate an emergency, therefore not requiring the nurse's first assessment.
Choice C rationale
Caput succedaneum is a localized swelling on the newborn's scalp that can cross suture lines, resulting from pressure during birth. While it is a notable finding, it is generally benign and resolves spontaneously within a few days, not indicating an immediate life-threatening condition requiring the first assessment.
Choice D rationale
An axillary temperature of 36° C (96.8° F) is below the normal range for a newborn, which is typically 36.5° C to 37.5° C (96.8° F to 99.5° F). Hypothermia in newborns can lead to significant metabolic demands, increased oxygen consumption, and potential for cold stress, making this newborn the priority for immediate assessment and intervention.
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