A nurse is reinforcing preoperative teaching with a client who is scheduled for a cesarean birth. Which of the following client statements indicates an understanding of the teaching?
"The nurse will take out my urinary catheter 48 hours after surgery."
"The nurse might need to massage my uterus frequently after surgery."
"I can have regular food once I am able to swallow safely."
"I will need to stay flat on my back in bed for the first 24 hours after surgery."
The Correct Answer is B
A. The urinary catheter is usually removed within the first 24 hours after a cesarean birth, not 48 hours. Early removal helps prevent complications and promotes recovery.
B. Uterine massage is performed to prevent postpartum hemorrhage and ensure the uterus is contracting properly. This practice is part of standard postpartum care to promote uterine involution.
C. Postoperative diet progression typically starts with clear liquids and advances as tolerated. Regular food is introduced once the client can swallow safely and shows no signs of nausea or gastrointestinal issues.
D. Staying flat on the back is not required post-cesarean section. Early ambulation is encouraged to prevent complications like deep vein thrombosis and to promote healing.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Witch hazel pads can soothe the perineal area and reduce discomfort from an episiotomy and hemorrhoids. This is a common and effective part of postpartum perineal care.
B. Heat packs are not recommended for episiotomy care as they can increase swelling. Instead, cold packs or ice can be used to reduce swelling and discomfort.
C. Numbing sprays should not be used prior to cleansing the area. Instead, gentle cleaning with mild soap and water is recommended for postpartum perineal care.
D. A sitz bath should typically be used for 15 to 20 minutes, not just 10 minutes, to effectively soothe the perineal area and promote healing.
Correct Answer is C
Explanation
A. Uterine contractions lasting 30 to 45 seconds
Rationale: Uterine contractions lasting 30 to 45 seconds are within the expected range for the latent phase of labor. This duration indicates that contractions are occurring but are not too frequent or too prolonged, which is typical for this stage of labor.
B. Uterine contractions every 6 min
Rationale: Contractions every 6 minutes are also typical for the latent phase of labor, where contractions are still becoming more frequent as labor progresses. This frequency does not suggest fetal distress or a significant risk to the fetus.
C. Recurrent variable deceleration of the FHR
Rationale: Recurrent variable decelerations in fetal heart rate (FHR) indicate that the fetus might be experiencing umbilical cord compression. This finding suggests a risk to the fetus, as it can be associated with reduced oxygenation and may require intervention to manage labor and optimize fetal well-being.
D. Moderate variability of the FHR
Rationale: Moderate variability in FHR is an indication of a well-oxygenated fetus and a healthy autonomic nervous system. This is a reassuring sign of fetal well-being rather than a risk.
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