When educating a group of postoperative clients who underwent a mastectomy, which immediate postoperative intervention is important for the nurse to consider when caring for these women?

The affected arm should not be elevated.

The affected arm should be used for intravenous (IV) therapy.

Venipuncture for blood work should be performed on the affected arm.

The blood pressure (BP) cuff should not be applied to the affected arm.

Answer and Explanation

The Correct Answer is D

A. The affected arm should be elevated on a pillow postoperatively to promote venous and lymphatic drainage, reduce swelling, and prevent lymphedema. Elevation is a critical part of early recovery, and avoiding it would increase the risk of fluid accumulation and discomfort.

B. The affected arm should not be used for IV therapy because lymphatic drainage may have been compromised during the mastectomy. Introducing an IV or performing invasive procedures on this arm increases the risk of infection, impaired healing, and lymphedema, a potentially long-term complication.

C. Venipuncture or blood draws should also avoid the affected arm. Puncturing veins in this limb can lead to fluid accumulation, swelling, infection, and delayed healing. Bloodwork and injections should be performed on the unaffected arm or an alternate site to reduce these risks.

D. The blood pressure cuff should not be applied to the affected arm because repeated compression can impede lymphatic flow and increase the risk of lymphedema. The cuff should always be used on the unaffected arm, and if necessary, alternative methods for monitoring blood pressure (such as a thigh cuff) can be employed. This intervention is a standard precaution immediately after mastectomy and is emphasized during patient education to prevent long-term complications.

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Correct Answer is B

Explanation

A. While preterm infants are at increased risk for hypoglycemia due to limited glycogen stores and immature metabolic regulation, dexamethasone does not directly prevent hypoglycemia. Its pharmacologic action is not related to neonatal blood sugar management.

B. Dexamethasone is a corticosteroid given to pregnant clients at risk of preterm birth, typically between 24 and 34 weeks gestation. The medication crosses the placenta and stimulates fetal lung epithelial cells to produce surfactant, a substance that reduces alveolar surface tension, enabling the lungs to remain open for effective gas exchange after birth. By accelerating lung development, dexamethasone significantly reduces the risk of respiratory distress syndrome (RDS), intraventricular hemorrhage, necrotizing enterocolitis, and neonatal mortality. The most benefit is observed when delivery occurs 24–48 hours after the first dose but within 7 days of administration.

C. While corticosteroid therapy can have secondary benefits, including a reduction in intraventricular hemorrhage, this is not the primary purpose of dexamethasone administration. The main goal remains enhancing fetal lung maturity.

D. Dexamethasone is not a tocolytic and does not suppress preterm labor contractions. Tocolytic medications, such as magnesium sulfate, nifedipine, or indomethacin, are used for short-term suppression of uterine activity to allow time for corticosteroids to enhance fetal lung maturity.

A. Normal reflexes and no headache B. Trace protein in urine C. Blood pressure 107/70 mm Hg and trace proteinuria D. Blood pressure 170/110 mm Hg and +3 proteinuria

Correct Answer is D

Explanation

A. Normal reflexes and absence of headache are not consistent with severe preeclampsia. Severe preeclampsia often includes hyperreflexia, headache, visual disturbances, and other neurologic symptoms due to increased vascular resistance and cerebral edema.

B. Trace protein in urine is characteristic of mild preeclampsia, not severe preeclampsia. Severe cases typically demonstrate marked proteinuria (+2 to +4 on dipstick or >5 g/24 hours) alongside other systemic symptoms.

C. A blood pressure of 107/70 mm Hg with trace proteinuria is within normal limits and does not reflect preeclampsia, let alone severe preeclampsia. Severe preeclampsia requires significantly elevated blood pressure and other signs of end-organ involvement.

D. Blood pressure 170/110 mm Hg and +3 proteinuria represents the classic presentation of severe preeclampsia. Severe preeclampsia is defined by systolic BP ≥160 mm Hg or diastolic BP ≥110 mm Hg on two occasions and proteinuria ≥+3 on dipstick or ≥5 g/24 hours. These findings indicate significant vascular and renal involvement, requiring prompt monitoring and management to prevent complications such as eclampsia, HELLP syndrome, and maternal or fetal compromise.

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When educating a group of postoperative clients who underwent a mastectomy, which immediate postoperative intervention is important for the nurse to consider when caring for these women?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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