The nurse is caring for a client who had a cesarean section birth.
Which of the following would be the most important assessment to make?
If signs of infection are present at the incision site.
If they plan to return to work postpartum.
If signs of infection are present at the perineal site.
If their breasts fill by the 1st postpartum day.
The Correct Answer is A
Choice A rationale
A cesarean section is a major surgical procedure that creates an incision through the abdominal wall and uterus. The most crucial assessment post-operatively is for signs of infection at the incision site. This involves inspecting the site for erythema, warmth, purulent drainage, or dehiscence, which are indicators of surgical site infection. Surgical infections can lead to significant morbidity and mortality, making this assessment paramount.
Choice B rationale
A client's plan to return to work postpartum is an important consideration for discharge planning and psychosocial support. However, it is not a direct physiological or safety assessment in the immediate postpartum period. The priority in the acute recovery phase is to monitor for potential medical complications related to the surgery and childbirth, such as infection, hemorrhage, or thrombosis.
Choice C rationale
While a perineal assessment is necessary after a vaginal delivery, it is not the most important assessment for a client who had a cesarean section. The surgical incision is the primary site of potential complications, such as infection or hemorrhage. The focus should be on the surgical site as it poses the greatest risk for immediate postoperative complications.
Choice D rationale
Breast engorgement, or the filling of breasts with milk, typically occurs between the third and fifth postpartum days. It is a normal physiological process. Assessing for this on the first postpartum day is not a priority. The most critical assessments immediately following a cesarean section involve monitoring for surgical complications, maternal vital signs, and uterine status.
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Correct Answer is C
Explanation
Choice A rationale
Adjusting the intravenous fluid infusion rate is not the immediate priority after an amniotomy. The primary concern is the potential for umbilical cord prolapse due to the gush of amniotic fluid, which can compromise fetal oxygenation. The fluid rate can be addressed after ensuring fetal well-being.
Choice B rationale
Providing a clean gown and linens is important for client comfort and hygiene but is not a priority over assessing fetal status. A change in linens can be done after the immediate safety of the fetus is confirmed, as a compromised fetal heart rate requires immediate intervention.
Choice C rationale
Assessing the fetal heart rate is the highest priority action after an amniotomy. The sudden release of amniotic fluid increases the risk of an umbilical cord prolapse, where the cord can be compressed, leading to a sudden decrease in fetal oxygenation and an emergent bradycardia. The normal fetal heart rate is 110-160 beats per minute.
Choice D rationale
Assisting the client with perineal hygiene is an important comfort measure and infection prevention strategy, but it is not the most critical and immediate action. The potential for a sudden, life-threatening change in fetal status due to cord prolapse takes precedence over hygiene.
Correct Answer is C
Explanation
Choice A rationale
Preparing for a vaginal delivery is not the immediate first action. The fetal heart rate pattern indicates potential fetal distress, which needs to be addressed and corrected before any definitive decisions about the mode of delivery are made. The priority is to improve uteroplacental blood flow and fetal oxygenation.
Choice B rationale
Administering oxygen at 8 to 10 liters via nasal cannula may be a secondary intervention if turning the client is not effective. The primary cause of late decelerations is uteroplacental insufficiency. While oxygen can help, the initial and most effective intervention is to reposition the mother to improve blood flow.
Choice C rationale
Late decelerations, which are characterized by a gradual decrease in fetal heart rate after the peak of a contraction and a gradual return to baseline after the contraction has ended, are most often caused by uteroplacental insufficiency. Turning the client on their side, particularly the left side, relieves pressure on the vena cava, improving venous return to the heart, which in turn increases uteroplacental blood flow and fetal oxygenation.
Choice D rationale
Performing a vaginal exam to assess for the umbilical cord is the appropriate intervention for variable decelerations, not late decelerations. Variable decelerations are caused by umbilical cord compression. A vaginal exam would not address the underlying issue of uteroplacental insufficiency responsible for late decelerations.
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