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 B

A. An indwelling urinary catheter is typically inserted before surgery, not immediately after, to keep the bladder empty during the procedure.
B. Applying sequential compression devices prior to the procedure is a key intervention to prevent deep vein thrombosis, which is a high-risk complication for clients undergoing cesarean birth.
C. Performing a surgical timeout is important but is a standard surgical protocol rather than a nursing-specific intervention for cesarean birth preparation.
D. Oxytocin is administered after delivery of the placenta to promote uterine contraction and prevent postpartum hemorrhage, not before surgery.

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Correct Answer is ["B","E"]

Explanation

A. Maternal Rh factor – The mother is O positive. Rh incompatibility is not a concern here because both mother and newborn are likely Rh positive, and no information suggests Rh incompatibility.
B. Gestational age – The newborn was born at 36 weeks and 4 days, which is considered late preterm and places the infant at increased risk for complications such as respiratory distress, jaundice, hypoglycemia, and feeding difficulties.
C. Apgar scores – Scores of 7 at 1 minute and 8 at 5 minutes are within the normal range and not indicative of distress or a complication risk.
D. Weight – A birth weight of 3,062 g (6 lb 12 oz) is appropriate for gestational age and not a risk factor.
E. Type of birth – Operative vaginal birth using a vacuum extractor increases the risk for complications like cephalohematoma, which is noted in the assessment (firm, edematous scalp area with ecchymosis not crossing suture lines). This can contribute to jaundice.
F. Length – A length of 48 cm (19 in) is appropriate for gestational age and not a risk factor.

A. Hypertension B. Bradypnea C. Tachycardia D. Polyuria

Correct Answer is C

Explanation

A. Hypotension, not hypertension, is expected in hemorrhagic shock due to blood loss.
B. Tachypnea, not bradypnea, usually occurs as the body tries to compensate for hypoxia.
C. Tachycardia is an early compensatory response to blood loss to maintain cardiac output.
D. Oliguria (decreased urine output), not polyuria, is expected due to poor perfusion of kidneys in shock.

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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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Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn Exhibits Which findings are risk factors for the newborn to develop a complication? Select all that apply

Correct Answer is ["B","E"]

Explanation

A nurse is assessing a client who is postpartum and is experiencing hemorrhagic shock. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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