A nurse is assessing for pain for a client following a cesarean birth 24 hr ago. Which of the following questions should the nurse ask to determine if a PRN pain medication is indicated?
"Have you noticed any swelling in your feet?"
"Do you have any leakage from your incision?"
"Do you notice increased cramping with breastfeeding?"
"Are you able to pass gas?"
The Correct Answer is C
Explanation
Choice A Reason:
"Have you noticed any swelling in your feet?" This question is inappropriate. Swelling in the feet is not directly related to postoperative pain following a cesarean birth. While swelling may indicate other issues such as fluid retention, it is not typically a primary indicator of pain requiring PRN pain medication.
Choice B Reason:
"Do you have any leakage from your incision?" This question is inappropriate. Leakage from the incision may indicate wound complications such as infection or dehiscence, but it does not specifically assess pain. PRN pain medication would be indicated based on the client's reported pain level, rather than the presence of incisional leakage alone.
Choice C Reason:
"Do you notice increased cramping with breastfeeding?" This question is appropriate. After a cesarean birth, it is common for women to experience cramping, especially during breastfeeding. This is due to the release of oxytocin, a hormone that helps the uterus contract back to its pre-pregnancy size. Increased cramping with breastfeeding can exacerbate postoperative pain in women who have undergone a cesarean birth. Therefore, asking about increased cramping with breastfeeding is an important question to assess pain and determine if additional pain medication is needed.
Choice D Reason:
"Are you able to pass gas?" This question is inappropriate. Passing gas is an important aspect of gastrointestinal function but is not directly related to postoperative pain following a cesarean birth. While constipation and gastrointestinal issues can contribute to discomfort, asking about the ability to pass gas does not specifically assess pain or indicate the need for PRN pain medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Explanation
Choice A Reason:
"Do your contractions feel further apart?" This question does not directly assess the effectiveness of the hands-and-knees position in rotating the baby or relieving discomfort associated with occipitoposterior position. It focuses on the timing of contractions rather than the impact of the position change.
Choice B Reason:
"Are you feeling relief from your pelvic pressure?" Pelvic pressure is more associated with the descending fetus and the overall labor process. The hands-and-knees position is mainly intended to alleviate back pain caused by the fetus's occipitoposterior position, rather than pelvic pressure.
Choice C Reason:
"Has your back labor improved?" The hands-and-knees position is often used to help alleviate back labor, a common issue with a fetus in the occipitoposterior position. The pressure from the fetal head on the mother's spine can cause significant back pain, and the hands-and-knees position can help by shifting the fetal position slightly and relieving some of this discomfort.
Choice D Reason:
"Does that lessen your suprapubic pain?" Suprapubic pain is more related to the pressure of the descending fetus on the bladder and the lower uterus. While the hands-and-knees position may alleviate some discomfort, it is primarily aimed at relieving back labor caused by the occipitoposterior position, not suprapubic pain.
Correct Answer is C
Explanation
Explanation
Choice A Reason:
Applying an ice pack to the incision site may provide comfort but does not address the underlying cause of the vaginal bleeding. Additionally, applying cold therapy to the incision site may not be recommended immediately after surgery as it can interfere with wound healing.
Choice B Reason:
Administering 500 mL lactated Ringer's IV bolus is inappropriate. While administering IV fluids may be indicated in the management of postpartum hemorrhage to support intravascular volume, it should be based on a comprehensive assessment of the client's condition and vital signs, including blood pressure and heart rate. Administering fluids without a thorough evaluation may not address the underlying cause of the bleeding and could potentially exacerbate the situation.
Choice C Reason:
Evaluating urinary output is inappropriate. Steady vaginal bleeding that persists despite fundal massage after a cesarean birth may indicate postpartum hemorrhage (PPH). PPH is a serious complication that requires prompt assessment and intervention. One of the primary causes of PPH is uterine atony, which is when the uterus fails to contract adequately after delivery.
Choice D Reason:
Replacing the surgical dressing is inappropriate. While maintaining a clean and dry surgical dressing is important for wound care, it does not address the underlying cause of the vaginal bleeding. In this situation, the priority is to assess and manage the potential causes of postpartum hemorrhage, such as uterine atony and urinary retention.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.