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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Document the infiltration: While documentation is an important part of the nursing process, it is not the first action to take. If an infiltration is suspected, the priority is to stop the infusion immediately to prevent further harm or fluid leakage into the surrounding tissues. Once the infusion is stopped, the nurse can then document the infiltration for medical record purposes.
B) Elevate the arm: Elevating the arm can help reduce swelling, but this should not be the first step. The first priority when infiltration is suspected is to stop the infusion, as continuing it can worsen the tissue damage and swelling. After stopping the infusion, elevating the arm may be considered as part of the subsequent management of the infiltration.
C) Apply a warm compress: A warm compress may be helpful after stopping the infusion, particularly if the infiltration involves non-vesicant fluids. However, applying a warm compress is not the immediate action. The first step should be stopping the infusion to prevent any further fluid from infiltrating the tissues.
D) Stop the infusion: The most immediate and appropriate action when infiltration is noted around the IV insertion site is to stop the infusion. This prevents additional fluid from leaking into the surrounding tissues, which could cause further damage. Once the infusion is stopped, the nurse can take other steps to manage the infiltration, such as assessing the site, applying a warm compress, or notifying the healthcare provider.
Correct Answer is B
Explanation
A) Encourage the family to be with the child during mealtimes: While family support during mealtimes can be helpful, it is not the first priority in this situation. The most important step is to understand the child’s dietary habits and challenges in order to create a more targeted and effective approach to addressing the poor dietary intake.
B) Obtain the child’s dietary history: The first step should be to gather information about the child’s dietary history. Understanding what the child is eating, how often, and any potential barriers to proper nutrition (e.g., food preferences, allergies, or cultural practices) is crucial for identifying the root cause of the poor dietary intake. This information will guide the nurse in making appropriate recommendations for improving the child's nutrition.
C) Instruct the family to praise the child when they eat: While positive reinforcement can be a useful strategy, it is not the first step in addressing poor dietary intake. The nurse needs to assess the child’s dietary habits and any possible issues before recommending specific behavioral strategies.
D) Offer the child nutritious snacks between meals: Offering nutritious snacks is a good strategy for improving a child’s nutrition, but it should come after gathering a clear understanding of the child’s eating habits. Without knowing the child’s preferences and needs, it’s better to first assess and identify the cause of the poor intake before recommending snacks.
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.