A nurse is caring for a client who delivered a newborn by caesarean section birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse take
You can splint the incision with a pillow when changing positiion
You should change position as little as possible
You should use patterned paced breathing when changing positions
You can apply counterpressure to your back with each position change
The Correct Answer is A
A) You can splint the incision with a pillow when changing position: Splinting the incision with a pillow is an excellent nonpharmacological method to manage pain during position changes after a cesarean section. The pillow helps provide support to the incision site, reduces strain on the abdominal muscles, and minimizes discomfort when the client moves. This is a safe and effective intervention to help with pain management.
B) You should change position as little as possible: While minimizing movement might seem like a way to prevent pain, it can lead to complications like muscle stiffness, poor circulation, and respiratory issues. It’s important for clients to change positions to promote comfort, circulation, and lung expansion, but they should do so with support to manage pain effectively.
C) You should use patterned paced breathing when changing positions: Patterned paced breathing is a helpful relaxation technique that can be used in various situations, including labor and delivery. However, it is not the most appropriate response in this context, as the client’s pain is more related to physical discomfort from the incision, and physical support (like splinting the incision) would be more effective in managing this type of pain.
D) You can apply counterpressure to your back with each position change: While counterpressure can be beneficial for back pain during labor, it is not the most relevant technique for managing pain after a cesarean section, where the pain is related to the abdominal incision site. Splinting the incision provides more targeted support for post-cesarean discomfort.
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Related Questions
Correct Answer is C
Explanation
A) Impetigo contagiosa: Impetigo contagiosa is a bacterial skin infection caused by either Staphylococcus aureus or Streptococcus pyogenes. While it is contagious, it is not typically required to be reported to the state health department, as it is not considered a high-priority communicable disease that mandates immediate reporting.
B) Sarcoptes scabiei: Scabies, caused by the mite Sarcoptes scabiei, is a contagious parasitic skin infection. Although scabies can be easily spread, it is generally not a reportable disease to the state health department unless there is an outbreak in a specific setting, such as a healthcare facility or school.
C) Neisseria gonorrhoeae: Neisseria gonorrhoeae, the bacterium that causes gonorrhea, is a sexually transmitted infection (STI) that is required by law to be reported to the state health department. Gonorrhea is a notifiable disease because of its potential for rapid transmission, complications, and its increasing resistance to antibiotics. Early reporting helps control the spread and provides opportunities for public health interventions.
D) Human papillomavirus (HPV): Human papillomavirus (HPV) is a viral infection that is not required to be reported to the state health department. While HPV is the most common STI and can lead to cancers such as cervical cancer, it is not mandated for reporting as an individual infection. However, certain types of HPV-related cancers may be tracked through cancer registries.
Correct Answer is A
Explanation
A) Measure the client’s vital signs: The first priority after a fall is to assess the client's physical condition to determine if any immediate harm or injury has occurred. Taking the vital signs allows the nurse to assess for signs of shock, internal injury, or other complications that could require urgent intervention. This step should be done before notifying the provider or completing paperwork.
B) Notify the client's provider: While notifying the provider is important, it is not the first step. The nurse's priority is to assess the client’s condition and ensure they are stable. Once the client’s condition has been assessed, the provider can be notified if necessary.
C) Complete an incident report: An incident report should be completed after the client’s immediate needs are addressed. While documentation of the fall is important, the priority is the client’s safety and well-being. The nurse should first evaluate and stabilize the client before focusing on administrative tasks like the incident report.
D) Document the fall in the client's medical record: Although documentation is essential, the first priority should always be assessing and stabilizing the client. Once the client’s safety is ensured, then documenting the event and any findings is appropriate.
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