A nurse is planning care for a client who is scheduled for a cesarean birth. Which of the following interventions should the nurse include in the plan of care?

Insert an indwelling urinary catheter immediately following the procedure.

Apply sequential compression devices prior to the procedure.

Perform a surgical timeout while the client is in the preoperative holding area.

Initiate oxytocin via continuous IV infusion prior to the procedure.

Answer and Explanation

The Correct Answer is C

A. An indwelling urinary catheter is typically inserted before or during the procedure, not after.
B. Sequential compression devices are important to prevent venous thromboembolism but are usually applied before or during the procedure; this option is partially correct but less critical than the timeout.
C. Performing a surgical timeout is a critical safety step conducted in the preoperative holding area to verify patient identity, procedure, and site.
D. Oxytocin is usually started after delivery to promote uterine contraction, not prior to surgery.

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Correct Answer is {"A":{"answers":"B,C"},"B":{"answers":"B,C"},"C":{"answers":"A,C"},"D":{"answers":"B,C"},"E":{"answers":"C"}}

Explanation

Assessment findings	Placenta previa	Preterm labor	Abruption placenta
Cervical dilation		✓	✓
Uterine contractions		✓	✓
Vaginal bleeding	✓		✓
Client reports low back pain		✓	✓
Abdominal tenderness			✓

Rationale

Cervical dilation: Present in preterm labor and abruption due to uterine activity and cervical changes; not typical in placenta previa unless labor begins.
Uterine contractions: Present in preterm labor and abruption; placenta previa usually painless without contractions.
Vaginal bleeding: In placenta previa, bleeding is usually painless; in abruption, bleeding is often accompanied by pain; preterm labor usually does not involve bleeding.
Low back pain: Common in preterm labor and abruption due to contractions or placental separation; not typical in placenta previa.
Abdominal tenderness: Present in abruption because of bleeding behind the placenta causing uterine irritation; absent in placenta previa and preterm labor.

A. Decrease the rate of the IV infusion. B. Place the client in a knee-chest position. C. Instruct the client to push with the next contraction. D. Replace the umbilical cord into the cervix

Correct Answer is B

Explanation

A. Decreasing IV infusion rate does not relieve umbilical cord prolapse.
B. Placing the client in a knee-chest position helps relieve pressure on the prolapsed umbilical cord, improving fetal oxygenation until delivery.
C. Instructing the client to push can worsen cord compression and is contraindicated.
D. The nurse should not attempt to replace the umbilical cord into the cervix; this is a sterile procedure typically performed by the provider.

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A nurse is planning care for a client who is scheduled for a cesarean birth. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"B,C"},"B":{"answers":"B,C"},"C":{"answers":"A,C"},"D":{"answers":"B,C"},"E":{"answers":"C"}}

Explanation

A nurse is caring for a client who is in the active phase of labor. The nurse palpates the umbilical cord during a vaginal examination. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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