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 ["A","B"]
Explanation
The correct answer is choice A and B. The nurse should place the patient in knee-chest or Trendelenburg position to relieve the pressure of the fetal presenting part on the prolapsed cord and improve fetal oxygenation.These positions also allow gravity to help keep the cord in the uterus and prevent further descent.
Choice C is wrong because supine position can worsen cord compression and compromise fetal blood flow.Choice D is wrong because lithotomy position can also increase cord descent and reduce fetal perfusion.Choice E is wrong because Sims position can cause cord prolapse if the membranes are intact or rupture spontaneously.
Normal ranges for fetal heart rate are 110 to 160 beats per minute.Cord prolapse can cause fetal bradycardia with decelerations during contractions due to cord compression.
This is a sign of fetal distress and requires immediate intervention.
Correct Answer is B
Explanation
The correct answer is choice B. The cord is hidden, often next to but not in front of the fetal head.This is called anoccult cord prolapseand it occurs when the umbilical cord descends alongside–but not past–the presenting part of the baby.Occult cords can occur with ruptured or intact membranes.They can cause hypoxia, brain injury, and permanent disability in a baby, so medical personnel must address them rapidly and appropriately.
Choice A is wrong because it describes anovert cord prolapse, which means that the cord slips down into your cervix and vagina ahead of your baby during delivery.This is a medical emergency that can cut off your baby’s blood and oxygen supply during delivery.
Choice C is wrong because it describes avisible cord prolapse, which is a type of overt cord prolapse where the cord is visible or palpable outside of the vagina.This is also a medical emergency that requires immediate delivery.
Choice D is wrong because it describes anuchal cord, which means that the cord is wrapped around the fetal neck or body.This is not a prolapse, but it can cause complications such as reduced blood flow, fetal distress, or umbilical cord strangulation.
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