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."

Answer and Explanation

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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Correct Answer is A

Explanation

A. Blurred vision can indicate a prenatal complication, such as preeclampsia, which is a serious condition that can develop in the later stages of pregnancy and requires immediate attention. Preeclampsia can lead to severe health issues for both the mother and baby.
B. Shortness of breath can be a normal part of late pregnancy due to the pressure on the diaphragm from the growing uterus. While it should be monitored, it is not specifically indicative of a complication compared to other symptoms.
C. Non-pitting ankle edema is common in the later stages of pregnancy and is not necessarily a sign of a complication on its own. It can occur due to the increased fluid volume and pressure from the uterus.
D. Leukorrhea, or increased vaginal discharge, is a common and normal finding in pregnancy, especially as labor approaches. It is generally not a sign of a complication unless accompanied by other concerning symptoms.

A. The newborn's legs flex at the knees and hips when pressure is applied to the soles of the newborn's feet. B. The newborn turns their head away from the stimulus when their cheek is touched. C. The newborn's fingers curl around the nurse's finger when placed in the newborn's palm. D. The newborn closes their eyes and keeps them closed when tapped on the forehead.

Correct Answer is C

Explanation

A. This describes the stepping reflex, which involves the newborn's legs moving in a stepping motion when the soles of the feet touch a surface, not just flexing at the knees and hips. It is expected but not the most relevant to the of reflex elicitation as stated.
B. The newborn turns toward the stimulus when their cheek is touched, not away. This is known as the rooting reflex, which helps the newborn find the breast or bottle for feeding.
C. The newborn's fingers curling around the nurse's finger is the grasp reflex, a normal and expected finding in newborns. It indicates normal neurological development and reflex activity.
D. The newborn blinking in response to a tap on the forehead is known as the glabellar reflex, but they do not typically keep their eyes closed. It is not a primary reflex assessed in newborns for neurological health.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 41 weeks of gestation. The nurse should understand that which of the following findings can indicate a prenatal complication in this client?

Correct Answer is A

Explanation

A nurse is collecting data from a newborn who was delivered at 40 weeks of gestation. Which of the following is an expected finding when eliciting reflexes from the newborn?

Correct Answer is C

Explanation

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