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
Explanation
The correct answer is choice A. “I will avoid squatting or sitting on the toilet after my water breaks.” This statement indicates that the patient understands how to prevent umbilical cord prolapse, which is a rare but serious complication that occurs when the umbilical cord slips out of the cervix before the baby during labor.This can cut off the baby’s blood and oxygen supply and require immediate delivery.
Choice B is wrong because drinking plenty of fluids does not affect the amniotic fluid level, which is determined by the placenta and the baby’s kidneys.Excessive amniotic fluid (polyhydramnios) can actually increase the risk of umbilical cord prolapse.
Choice C is wrong because monitoring the baby’s movements does not prevent umbilical cord prolapse, although it can help detect fetal distress if the cord is compressed.Decreased fetal movements can have other causes besides cord prolapse, such as fetal sleep cycle, maternal medication, or placental insufficiency.
Choice D is wrong because sleeping on the left side does not prevent umbilical cord prolapse, although it can improve blood flow to the baby and reduce the risk of supine hypotension syndrome.Umbilical cord prolapse can occur regardless of the maternal position.
Normal ranges for amniotic fluid index (AFI) are 5 to 25 cm.Normal ranges for fetal heart rate (FHR) are 110 to 160 beats per minute (bpm).
Correct Answer is B
Explanation
The correct answer is choice B. Umbilical cord compression.Variable decelerations are the most common type of fetal deceleration and they are caused by compression of the umbilical cord.They vary in shape, duration, and intensity and may not have a constant relationship with uterine contractions.
Choice A is wrong because uteroplacental insufficiency is the cause of late decelerations, not variable decelerations.Uteroplacental insufficiency is a decrease in the blood flow to the placenta that reduces the amount of oxygen and nutrients transferred to the fetus.
Choice C is wrong because maternal hypotension is one of the possible causes of late decelerations, not variable decelerations.Maternal hypotension can reduce the uteroplacental blood flow and cause fetal hypoxia.
Choice D is wrong because fetal head compression is the cause of early decelerations, not variable decelerations.Early decelerations are benign and uniform in shape and they occur when the fetal head is pressed against the cervix during a uterine contraction.
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