A client had a laparoscopic bilateral tubal ligation (BTL) in the delivery room. Which intervention should a nurse plan to include in this client’s postoperative care?

Provide the client with an abdominal binder.

Provide a rocking chair at the client’s bedside.

Keep the head of the client’s bed flat for six hours.

Encourage the client to drink cold, carbonated fluids throughout the day.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D. Encourage the client to drink cold, carbonated fluids throughout the day.This helps to relieve the shoulder pain caused by the carbon dioxide gas used to inflate the abdomen during laparoscopy.

The gas irritates the diaphragm, which refers pain to the shoulder. Drinking cold, carbonated fluids can help expel the gas and reduce the pain.

Choice A is wrong because an abdominal binder is not necessary for a laparoscopic procedure. It is more commonly used for abdominal surgeries that involve a large incision.

Choice B is wrong because a rocking chair is not helpful for a client who had a laparoscopic BTL. It is more useful for a client who had a vaginal delivery to promote comfort and uterine involution.

Choice C is wrong because keeping the head of the bed flat for six hours is not indicated for a laparoscopic BTL. It may increase the risk of venous thromboembolism and pulmonary embolism due to prolonged immobility. The client should be encouraged to ambulate as soon as possible after surgery.

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Correct Answer is A

Explanation

The correct answer is choice A.Making a loud sound within close range of the newborn will elicit the Moro reflex, which is an involuntary protective motor response against abrupt disruption of body balance or extremely sudden stimulation.The Moro reflex involves three distinct components: spreading out the arms (abduction), pulling the arms in (adduction), and crying (usually).

Choice B is wrong because firmly stroking the soles of the newborn’s feet with a thumb nail will elicit the Babinski reflex, which is a normal response in infants that involves fanning out and curling of the toes.

Choice C is wrong because using the newborn’s hands to raise the baby from a supine position without supporting the head will elicit the traction response, which is a normal response in infants that involves flexion of the elbows and shoulders.

Choice D is wrong because holding the newborn in an upright position so that the infant’s feet touch a cool, flat surface will elicit the stepping reflex, which is a normal response in infants that involves alternating steps with each foot.

A. “I should expect a few spots of blood on my underwear because I have more blood in my body now.”. B. “Clear fluid will leak from my vagina if my baby is surrounded by too much water in my womb.”. C. “If I begin to see dark patches on my face, it means that my blood pressure is rising.”. D. “If I feel like I have butterflies in my stomach, it means my baby is moving.”.

Correct Answer is D

Explanation

The correct answer is choice D. If the client feels like she has butterflies in her stomach, it means her baby is moving.

This is a normal and expected change during pregnancy, especially in the second and third trimesters.The baby’s movements can be felt as flutters, kicks, or rolls.

Choice A is wrong because spotting of blood on the underwear is not a normal change during pregnancy.

It can indicate a problem such as placenta previa, placental abruption, or miscarriage.Any bleeding during pregnancy should be reported to the health care provider.

Choice B is wrong because clear fluid leaking from the vagina is not a normal change during pregnancy.

It can indicate that the membranes have ruptured and amniotic fluid is escaping.

This can lead to infection and preterm labor if not treated promptly.Any fluid leakage during pregnancy should be reported to the health care provider.

Choice C is wrong because dark patches on the face are not a sign of high blood pressure during pregnancy.

They are called melasma or chloasma and are caused by increased pigmentation due to hormonal changes.They usually fade after delivery and are not harmful.High blood pressure during pregnancy can cause symptoms such as headache, blurred vision, swelling, and protein in the urine.

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A client had a laparoscopic bilateral tubal ligation (BTL) in the delivery room. Which intervention should a nurse plan to include in this client’s postoperative care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a newborn, which is the best method for the nurse to use to elicit the Moro reflex?

Correct Answer is A

Explanation

The nurse provides a 16-year-old client with information concerning expected and possible changes during pregnancy. Which statement, if made by the client, would indicate that she understands the information?

Correct Answer is D

Explanation

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