Nokea
Which preoperative nursing interventions should be included for a client who is scheduled to have an emergency cesarean birth?
- A. Monitor oxygen saturation and administer pain medication.
- B. Assess vital signs every 15 minutes and instruct the client about postoperative care. Alleviate anxiety and insert an indwelling catheter.
- C. Perform a sterile vaginal examination and assess breath sounds.
- D. Because this is an emergency, surgery must be performed quickly. Anxiety of the client and the family will be high. Inserting an indwelling catheter helps to keep the bladder empty and free from injury when the incision is made.
Correct Answer: B
Rationale: The correct answer is B. Assessing vital signs every 15 minutes is crucial in an emergency cesarean birth to monitor the client's condition. Instructing the client about postoperative care ensures they are well-prepared. Alleviating anxiety is important for the client's emotional well-being. Inserting an indwelling catheter is also necessary for bladder emptying to prevent injury during surgery. Choice A is incorrect because oxygen saturation monitoring is not typically a preoperative intervention for a cesarean birth, and administering pain medication may not be necessary preoperatively. Choice C is incorrect as a sterile vaginal examination is not indicated before a cesarean birth, and assessing breath sounds does not directly relate to preoperative care for this procedure. Choice D is incorrect because although anxiety management and indwelling catheter insertion are important, the rationale provided is not directly related to preoperative care for a cesarean birth.
You may also like to solve these questions
A client is admitted to the hospital with severe pregnancy-induced hypertension (PIH). The physician orders magnesium sulfate. Which nursing intervention is important when administering this drug?
- A. Assess blood pressure and respiratory rate every fifteen minutes
- B. Monitor blood glucose levels every eight hours
- C. Evaluate for orthostatic hypotension when getting the client up to walk
- D. Observe for premature labor every shift
Correct Answer: A
Rationale: The correct answer is A because magnesium sulfate is a central nervous system depressant used to prevent seizures in PIH. It can cause respiratory depression and hypotension. Assessing blood pressure and respiratory rate every fifteen minutes is crucial to monitor for signs of magnesium toxicity and ensure the client's safety. Monitoring blood glucose levels (B) is not directly related to magnesium sulfate administration. Evaluating for orthostatic hypotension (C) and observing for premature labor (D) are not specific to the administration of magnesium sulfate in treating PIH.
When planning for the care of an infant experiencing neonatal abstinence syndrome, which nursing assessment is most important?
- A. The mother's ability to provide a safe environment
- B. The extent of addiction of the mother
- C. The mother's ability to obtain treatment
- D. The severity of the infant's withdrawal
Correct Answer: A
Rationale: The correct answer is A: The mother's ability to provide a safe environment. This is crucial because infants with neonatal abstinence syndrome require a stable and safe environment for optimal care and recovery. Assessing the mother's ability to provide this environment helps ensure the infant's safety and well-being. Choice B is incorrect because the extent of the mother's addiction, while important, does not directly impact the immediate care of the infant. Choice C is incorrect as the focus should be on the current situation and care of the infant rather than the mother obtaining treatment. Choice D is incorrect as the severity of the infant's withdrawal, though important, is not the most critical assessment in planning care.
A nurse is checking children at an orthopedic outpatient setting. Which of the following should the nurse expect to see as manifestations of scoliosis?
- A. Pain and an exaggerated lumbar curvature'
- B. Uneven shoulder heights and poorly fitting slacks'
- C. Tenderness and swelling of the spine'
- D. Limited range of motion of the back and a limp'
Correct Answer: B
Rationale: The correct answer is B. Uneven shoulder heights and poorly fitting slacks are common manifestations of scoliosis because the condition causes an abnormal curvature of the spine, leading to uneven shoulders and hips. Pain and exaggerated lumbar curvature (choice A) are not specific manifestations of scoliosis. Tenderness and swelling of the spine (choice C) could indicate other conditions like infection or inflammation, not necessarily scoliosis. Limited range of motion of the back and a limp (choice D) are more indicative of musculoskeletal injuries or disorders, not scoliosis.
A postterm infant is delivered by cesarean section because of fetal distress and meconium-stained amniotic fluid. The nursery nurse frequently monitors the baby's respiratory rate, observing for tachypnea. Which is the reason for the nurse's actions? The infant may:
- A. experience respiratory depression from the medications used during delivery
- B. develop meconium aspiration pneumonia
- C. have an elevated temperature
- D. have a pneumothorax related to delivery
Correct Answer: B
Rationale: The correct answer is B: develop meconium aspiration pneumonia. Meconium-stained amniotic fluid can lead to the infant inhaling meconium, which can cause blockage and inflammation in the airways, leading to meconium aspiration pneumonia. This can result in respiratory distress, tachypnea, and potential complications like respiratory failure. The nurse monitors the respiratory rate to detect any signs of respiratory distress early on.
Incorrect choices:
A: Respiratory depression from medications used during delivery is less likely to be the cause of tachypnea in this scenario.
C: Elevated temperature is not directly related to meconium aspiration pneumonia or respiratory distress in this case.
D: A pneumothorax related to delivery is possible but less likely than meconium aspiration pneumonia as the cause of tachypnea in this case.
A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, ''happy one min and crying the next.'' The nurse should interpret the client's statement as an indication of which of the following?
- A. Emotional lability
- B. Focusing phase
- C. Cognitive restructuring
- D. Couvade syndrome
Correct Answer: A
Rationale: The correct answer is A: Emotional lability. Emotional lability refers to rapid, unpredictable changes in emotions. During pregnancy, hormonal fluctuations can lead to mood swings, causing the client to feel happy one minute and crying the next. Focusing phase (B) is not relevant to the client's emotional state. Cognitive restructuring (C) involves changing negative thought patterns, which is not mentioned in the scenario. Couvade syndrome (D) is a condition where male partners experience pregnancy-like symptoms, which is not applicable here.