Nokea
Intermittent positive pressure boots have been ordered for a client who had an emergency cesarean section. Which of the following is the rationale for that order?
- A. Postpartum clients are at high risk for thrombus formation.
- B. Post-cesarean clients are at high risk for fluid volume deficit.
- C. Postpartum clients are at high risk for varicose vein development.
- D. Post-cesarean clients are at high risk for poor milk ejection reflex.
Correct Answer: A
Rationale: Boots reduce thrombosis risk.
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A client is preparing to breastfeed her newborn son in the cross-cradle position. Which of the following actions should the woman make?
- A. Place a pillow in her lap.
- B. Position the head of the baby in her elbow.
- C. Put the baby on his back.
- D. Move the breast toward the mouth of the baby.
Correct Answer: A
Rationale: A pillow supports the baby and reduces strain.
A serum electrolyte report for a client, 1 day post-cesarean delivery for eclampsia, has just been received by the nurse. The client is receiving 5% dextrose in 1/2 normal saline IV at 125 mL/hr and magnesium sulfate 2 G/hr IV via infusion pump. Which of the following values should the nurse report to the surgeon?
- A. Magnesium 7 mg/dL.
- B. Sodium 136 mg/dL.
- C. Potassium 3.0 mg/dL.
- D. Calcium 9 mg/dL.
Correct Answer: A
Rationale: Elevated magnesium levels indicate toxicity.
When assessing the A of the acronym REEDA, the nurse should evaluate the
- A. skin color.
- B. degree of edem
- C. edges of the episiotomy.
- D. episiotomy for discharg
Correct Answer: C
Rationale: The correct answer is C. When assessing the A of REEDA (Redness, Edema, Ecchymosis, Discharge, and Approximation) in wound assessment, nurses should evaluate the edges of the episiotomy. This is important to ensure proper healing and closure of the incision site. Evaluating skin color (A) is important for overall wound assessment but not specifically for the edges of the episiotomy. Edema (B) refers to swelling, which is important to monitor but not specific to the edges of the episiotomy. Checking the episiotomy for discharge (D) is relevant for the "D" component of REEDA but not for the "A" component, which specifically focuses on the edges of the incision.
The nurse is conducting discharge teaching for a patient going home after a cesarean birth. Which signs and symptoms should the patient be taught to report? (Select all that apply.)
- A. Mild incisional pain
- B. Feeling of pelvic fullness
- C. Lochia changing from red to pink in color
- D. Frequency, urgency, or burning on urination
Correct Answer: D
Rationale: The correct answer is D because frequency, urgency, or burning on urination could indicate a urinary tract infection, a common post-cesarean complication. Reporting these symptoms promptly can prevent further complications.
A, B, and C are incorrect. A mild incisional pain is normal after a cesarean birth and is expected during the healing process. Feeling of pelvic fullness may be due to postpartum changes in the body and is not necessarily concerning. Lochia changing from red to pink is a normal progression of lochia color and does not typically indicate a problem unless there are other concerning symptoms present.
A client has been receiving magnesium sulfate for severe preeclampsia for 12 hours. Her reflexes are 0 and her respiratory rate is 10. Which of the following situations could be a precipitating factor in these findings?
- A. Apical heart rate 104 bpm.
- B. Urinary output 240 mL/12 hr.
- C. Blood pressure 160/120.
- D. Temperature 100°F.
Correct Answer: B
Rationale: Decreased urinary output can lead to magnesium toxicity.