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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?

A.

"I can have regular food once I am able to swallow safely.”.

B.

"I will need to stay flat on my back in bed for the first 24 hours after surgery.”.

C.

"The nurse will take out my urinary catheter 48 hours after surgery.”.

D.

"The nurse might need to massage my uterus frequently after surgery.”.

Answer and Explanation

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

Wearing an underwire bra is not recommended for clients with inverted nipples as it can cause discomfort and restrict milk flow. Proper support without constriction is essential.

Choice B rationale

Placing breast shells in the client's bra helps to draw out inverted nipples by applying gentle pressure, making breastfeeding easier. They also protect the nipples from friction and irritation.

Choice C rationale

Providing plastic-lined breast pads may prevent leakage, but they do not address the issue of inverted nipples. Proper nipple preparation is essential for effective breastfeeding.

Choice D rationale

Applying breast cream regularly might keep the skin hydrated, but it does not help to correct the inversion of the nipples. Mechanical aids like breast shells are more effective.

Correct Answer is A

Explanation

Choice A rationale

Assisting the client's partner to apply counterpressure to the sacrum can help alleviate the low-back pain associated with early labor by providing direct pressure to the area experiencing discomfort.

Choice B rationale

Maintaining the client on bed rest until active labor begins is not typically recommended, as mobility can help with the progression of labor and pain management.

Choice C rationale

Inserting an indwelling urinary catheter is not necessary for managing low-back pain in early labor and can increase the risk of infection and discomfort.

Choice D rationale

Teaching the client to hold their breath during contractions is not advisable, as it can lead to increased pain and decreased oxygenation for both the mother and baby. Breathing techniques are usually recommended to manage pain and ensure adequate oxygen delivery. .

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