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 D

Explanation

A. Water retention is not a common adverse effect of methylergonovine.
B. Tachycardia is not typically caused by methylergonovine; bradycardia or hypertension is more common.
C. Seizures are not a common side effect of this medication.
D. Hypertension is a known adverse effect of methylergonovine and requires close monitoring, especially in clients with preexisting hypertension.

A. Pale blue hands and feet B. Soft grunting noises with respiration C. Blood-tinged discharge from the vagina D. Positive Babinski reflex

Correct Answer is B

Explanation

A. Pale blue hands and feet (acrocyanosis) are normal during the first 24 hours after birth.
B. Soft grunting noises can indicate respiratory distress and should be reported promptly.
C. Blood-tinged vaginal discharge (pseudomenstruation) is normal in newborn females due to maternal hormones.
D. A positive Babinski reflex is a normal neurologic finding in newborns.

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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

A nurse is assessing a client who received methylergonovine to treat uterine atony in the fourth stage of labor. Which of the following findings should the nurse identify as an adverse effect of the medication?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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