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 B

Explanation

A. There is no vaccine for hepatitis C; vaccines exist for hepatitis A and B.
B. Syphilis can be cured effectively with penicillin, especially in early stages.
C. Gonorrhea can be treated and cured with appropriate antibiotics.
D. Genital herpes simplex virus is a viral infection and cannot be cured with antibiotics; antiviral medications manage symptoms.

A. Insert an indwelling urinary catheter. B. Evaluate deep tendon reflexes. C. Determine motor function of lower extremities. D. Administer meperidine hydrochloride IV.

Correct Answer is C

Explanation

A. Catheterization may be necessary if the client cannot void but is not the first step before ambulation.
B. Evaluating deep tendon reflexes is more relevant for clients receiving magnesium sulfate, not primarily for epidural assessment.
C. Assessing motor function of the lower extremities ensures the client has adequate strength and sensation to safely ambulate after an epidural.
D. Administering meperidine is for pain management and does not relate to safety before ambulation.

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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?

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