A nurse is providing discharge teaching to a client who had a cesarean delivery due to cord prolapse.
Which of the following instructions should the nurse include in the teaching?
Avoid lifting anything heavier than the newborn for 6 weeks.
Resume sexual intercourse as soon as bleeding stops.
Take ibuprofen for pain relief as needed
Report any foul-smelling vaginal discharge to the provider.
The Correct Answer is A
The correct answer is choice A.
The nurse should instruct the client to avoid lifting anything heavier than the newborn for 6 weeks. This is because lifting heavy objects can strain the abdominal muscles and the incision site, and increase the risk of bleeding and infection.
Choice B is wrong because the nurse should advise the client to wait at least 4 to 6 weeks before resuming sexual intercourse. This is to allow the incision to heal and prevent infection and discomfort.
Choice C is wrong because the nurse should not recommend ibuprofen for pain relief as it can interfere with blood clotting and increase bleeding. The nurse should suggest acetaminophen or a prescribed analgesic instead.
Choice D is wrong because the nurse should not tell the client to report any foul-smelling vaginal discharge to the provider.
The client should expect some vaginal discharge (lochia) for several weeks after a cesarean delivery, which may have a mild odor. However, the nurse should instruct the client to report signs of infection such as fever, chills, redness, swelling, or increased pain at the incision site.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C.“I will come to the hospital as soon as my water breaks.” This statement indicates understanding of measures to prevent umbilical cord prolapse, which is a complication that occurs when the umbilical cord drops out of the cervix before the baby during labor.This can cut off the baby’s blood and oxygen supply and cause permanent brain damage.Immediate delivery by C-section is usually necessary.
Choice A is wrong because squatting or sitting on hard surfaces does not increase the risk of umbilical cord prolapse.
Choice B is wrong because decreased fetal movement is not a sign of umbilical cord prolapse, but rather a sign of fetal distress that may have other causes.
Choice D is wrong because drinking plenty of fluids and resting on the left side are general measures to promote maternal and fetal well-being, but they do not prevent umbilical cord prolapse.
Some of the risk factors for umbilical cord prolapse include premature rupture of membranes, multiple pregnancy, breech presentation, excessive amniotic fluid, abnormal length of the umbilical cord and premature delivery.Some of the symptoms of umbilical cord prolapse include visible or palpable cord after water breaks, fetal heart rate abnormalities and maternal feeling of something coming out of the vagina.Umbilical cord prolapse can be diagnosed by physical examination, ultrasound or fetal heart rate monitoring.
Correct Answer is A
Explanation
The correct answer is choice A. Normal involution.
This means that the uterus is returning to its pre-pregnancy size and position after delivery.
The fundus is the upper part of the uterus and it should be firm, midline, and gradually descend into the pelvis.A fundus that is 2 cm below the umbilicus at 4 hours postpartum is within the normal range.
Choice B. Subinvolution is wrong because it refers to a delayed or incomplete involution of the uterus.
This can result in prolonged bleeding, infection, or retained placental fragments.A fundus that is above the umbilicus, boggy, or displaced to one side may indicate subinvolution.
Choice C. Retained placenta is wrong because it means that some or all of the placenta remains in the uterus after delivery.
This can cause heavy bleeding, infection, or uterine atony.A fundus that is high, soft, or tender may indicate retained placenta.
Choice D. Endometritis is wrong because it means that the lining of the uterus is inflamed due to infection.
This can cause fever, foul-smelling lochia, pelvic pain, or uterine tenderness.A fundus that is enlarged, tender, or malodorous may indicate endometritis.
Normal ranges for fundal height after delivery are:
• Immediately after delivery:
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