What important, immediate postoperative care practice should the nurse remember when caring for a woman who has had a mastectomy?
Venipuncture for blood work should be performed on the affected arm.
The blood pressure (BP) cuff should not be applied to the affected arm.
The affected arm should be held down close to the woman's side.
The affected arm should be used for intravenous (IV) therapy.
The affected arm should be used for intravenous (IV) therapy.
The Correct Answer is B
Choice A reason: This is incorrect because venipuncture for blood work should be avoided on the affected arm. The mastectomy may have involved the removal of lymph nodes, which can impair the lymphatic drainage and increase the risk of lymphedema (swelling) in the arm. Venipuncture can cause further damage or infection to the arm.
Choice B reason: This is correct because the BP cuff should not be applied to the affected arm. The BP cuff can exert pressure on the arm and interfere with the blood and lymph flow. This can also increase the risk of lymphedema or pain in the arm.
Choice C reason: This is incorrect because the affected arm should not be held down close to the woman's side. The woman should be encouraged to elevate the arm above the level of the heart and perform gentle exercises to promote circulation and prevent stiffness. The arm should not be immobilized or restricted.
Choice D reason: This is incorrect because the affected arm should not be used for IV therapy. IV therapy can introduce fluids or medications into the arm that can affect the blood and lymph flow. It can also cause irritation or infection to the arm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Vibroacoustic stimulation is a technique that uses sound to stimulate the fetus and elicit a response. It is sometimes used in conjunction with the nonstress test (NST), not the CST. The NST measures the fetal heart rate (FHR) in response to fetal movement, while the CST measures the FHR in response to uterine contractions.
Choice B reason: A negative CST result means that the FHR does not show any late decelerations during at least three contractions in a 10-minute period. Late decelerations are decreases in the FHR that begin after the peak of a contraction and return to the baseline after the contraction ends. They indicate uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen and nutrients to the fetus. A negative CST result is reassuring and suggests that the fetus is well-oxygenated and can tolerate labor².
Choice C reason: The CST is not an invasive test, as it does not involve inserting any instruments or devices into the uterus or the fetus. However, it does require stimulating contractions, either by giving the pregnant woman oxytocin (a hormone that causes uterine contractions) or by having her rub her nipples (which also releases oxytocin). The contractions can be uncomfortable and may trigger preterm labor in some cases.
Choice D reason: The CST is not more effective than the NST if the membranes have already been ruptured. In fact, the CST is contraindicated (not recommended) in women who have ruptured membranes, as it can increase the risk of infection and bleeding. The NST is a safer and simpler alternative to the CST, as it does not require stimulating contractions. However, the NST may not be as reliable as the CST in detecting fetal compromise.
Correct Answer is ["B","C","D"]
Explanation
Choice A reason: Abstinence is the avoidance of sexual activity, which reduces the risk of exposure to STIs. It is not a sexual risk behavior.
Choice B reason: Multiple sex partners increases the likelihood of exposure to STIs, especially if the partners are not tested or treated. It is a sexual risk behavior.
Choice C reason: Unprotected anal intercourse exposes the mucous membranes of the rectum and anus to potential pathogens, which can cause STIs such as gonorrhea, chlamydia, syphilis, and HIV. It is a sexual risk behavior.
Choice D reason: Oral sex involves contact between the mouth and the genitals or anus, which can transmit STIs such as herpes, HPV, gonorrhea, and syphilis. It is a sexual risk behavior.
Choice E reason: Dry kissing is the contact between the lips without the exchange of saliva, which does not transmit STIs. It is not a sexual risk behavior.
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