A nurse is reinforcing preoperative teaching with a client who is scheduled for a cesarean birth. Which of the following client statements indicates an understanding of the teaching?
"I can have regular food once I am able to swallow safely.”.
"I will need to stay flat on my back in bed for the first 24 hours after surgery.”.
"The nurse will take out my urinary catheter 48 hours after surgery.”.
"The nurse might need to massage my uterus frequently after surgery.”.
The Correct Answer is D
Choice A rationale
This statement is incorrect because after a cesarean birth, clients are usually started on clear liquids and then gradually progress to regular food as tolerated. Swallowing safety is related to anesthesia recovery, not cesarean birth recovery.
Choice B rationale
This statement is incorrect because the client does not need to stay flat on their back for 24 hours. Early ambulation is encouraged to prevent complications such as deep vein thrombosis and promote recovery.
Choice C rationale
This statement is incorrect because the urinary catheter is typically removed within 24 hours after surgery to reduce the risk of urinary tract infections and encourage normal bladder function.
Choice D rationale
This statement is correct because after a cesarean birth, the nurse will frequently assess the uterus for firmness and massage it as needed to prevent postpartum hemorrhage.
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Correct Answer is B
Explanation
Choice A rationale
Using a disposable razor for shaving while taking warfarin can increase the risk of cuts and bleeding, which should be avoided due to the anticoagulant effects of warfarin.
Choice B rationale
Oral contraceptives should not be taken while on warfarin because they can increase the risk of blood clots, counteracting the effect of the anticoagulant.
Choice C rationale
Stopping warfarin in 2 weeks is incorrect advice, as the duration of therapy varies depending on the condition being treated and the individual's response to the medication.
Choice D rationale
Taking 650 milligrams of aspirin for leg discomfort is not advised while on warfarin, as aspirin can increase the risk of bleeding by affecting platelet function and the blood clotting process.
Correct Answer is A
Explanation
Choice A rationale
Fundus located to the right of the umbilicus requires intervention. This can indicate a full bladder, which can inhibit uterine contraction and increase the risk of postpartum hemorrhage.
Choice B rationale
A temperature of 37.8° C (100° F) is a common finding postpartum and usually does not require intervention unless it is accompanied by other signs of infection.
Choice C rationale
Deep tendon reflexes 2+ is a normal finding and does not require intervention. It indicates normal neuromuscular function.
Choice D rationale
A moderate amount of lochia rubra is expected postpartum and does not require intervention unless it is excessive or associated with other abnormal symptoms.