A nurse is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take?
Insert a pillow under the client's knees.
Assist the client into the lithotomy position,
Place a wedge under one of the client's hips.
Position the client in reverse Trendelenburg.
The Correct Answer is C
A) Insert a pillow under the client's knees: While placing a pillow under the knees may promote comfort, it can lead to increased pressure on the lower back and may not effectively address potential compression of the vena cava, which is crucial in maintaining optimal placental blood flow during surgery.
B) Assist the client into the lithotomy position: The lithotomy position can increase pressure on the abdominal vessels, potentially compromising blood flow to the placenta. This position should be used cautiously, especially in clients with concerns regarding blood flow.
C) Place a wedge under one of the client's hips: This action is appropriate as it helps to displace the uterus laterally, reducing pressure on the inferior vena cava. This maneuver improves venous return and maintains placental perfusion, which is critical during cesarean delivery.
D) Position the client in reverse Trendelenburg: Although this position elevates the upper body, it does not specifically address the potential for vena cava compression caused by the weight of the uterus. It is less effective than placing a wedge under the hips in terms of preserving placental blood flow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) "I should use a soft-bristle toothbrush to clean my teeth after meals.": Using a soft-bristle toothbrush is crucial for clients with stomatitis, as it minimizes irritation to sensitive oral tissues. Gentle oral hygiene practices help maintain oral health and reduce discomfort, indicating that the client understands the need for careful dental care during radiation therapy.
B) "I should limit my intake of dairy products to prevent nausea.": While some clients may experience nausea, limiting dairy is not typically recommended for managing stomatitis. In fact, dairy can be soothing for some individuals. This statement does not address the specific needs related to stomatitis and indicates a misunderstanding of dietary management during treatment.
C) "I should gargle with an alcohol-based mouthwash to kill germs.": Alcohol-based mouthwashes can further irritate the mucous membranes and exacerbate stomatitis symptoms. Acknowledging this would demonstrate a lack of understanding, as alcohol is contraindicated in the management of oral mucosal irritation caused by radiation therapy.
D) "I should moisten my lips with lemon-glycerin swabs.": Lemon-glycerin swabs can actually irritate the mouth and exacerbate discomfort in clients with stomatitis. This approach is not recommended, and selecting such a treatment indicates a misunderstanding of appropriate oral care measures during radiation therapy.
Correct Answer is A
Explanation
A) Determine if the client has thoughts about self-harm: In situations of acute grief and trauma, assessing for suicidal ideation is the priority. The nurse must ensure the client's safety first, as the loss of a partner in such a tragic circumstance can lead to overwhelming feelings of despair and hopelessness.
B) Review the client's available social support system: While understanding the client’s social support is important for ongoing care and coping strategies, it is not the immediate priority. Ensuring the client’s safety takes precedence over evaluating their support network.
C) Empower the client to feel that he is in charge of his life: Empowering the client is a valuable goal for long-term recovery, but it should come after assessing immediate safety and mental health needs. The client may not be in a state to feel empowered until basic concerns about their well-being are addressed.
D) Find the client a temporary shelter where he can feel safe: While finding shelter is crucial for the client’s physical safety and security, this action should follow the immediate assessment of the client’s mental health and any risk of self-harm. Ensuring psychological safety is the first step before addressing logistical needs.
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