A nurse is caring for a female client who is primigravida at 30 weeks of gestation in the antepartum unit.

For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

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.

Choice A rationale

A BUN level of 25 mg/dL is above the normal range of 10 to 20 mg/dL for pregnant clients. Elevated BUN can indicate impaired renal function, which can be a complication of pregnancy, particularly in conditions like preeclampsia or underlying kidney disease. This finding, especially in a client with a history of anemia, warrants further investigation as it suggests potential kidney compromise affecting waste product excretion.

Choice B rationale

A hemoglobin (Hgb) level of 10.2 mg/dL is slightly below the normal range of 11 to 16 mg/dL for pregnant clients. Given the client's history of anemia, this finding is consistent with their known condition and, while it indicates mild anemia, it might not necessarily represent a new acute prenatal complication requiring immediate report unless there is a significant drop or associated symptoms. Iron supplementation is typically initiated for this level.

Choice C rationale

A fasting blood glucose of 70 mg/dL is within the normal range of 70 to 110 mg/dL. This indicates adequate glucose regulation and does not suggest a prenatal complication such as gestational diabetes. Maintaining a normal fasting blood glucose is a positive indicator for maternal and fetal well-being, especially for a client without a history of diabetes.

Choice D rationale

A hematocrit (Hct) level of 32% is slightly below the normal range of 33 to 47% for pregnant clients. Similar to hemoglobin, a slightly low hematocrit is common in pregnancy due to hemodilution, where plasma volume increases more significantly than red blood cell mass. While it indicates mild physiological anemia, it is often managed with dietary adjustments or iron supplements and does not typically signify an acute prenatal complication requiring immediate report.