Question 1

The nurse is caring for a patient recovering from a cesarean birth. Which assessment should the nurse make a priority for this patient?

Accepted Answer

After a cesarean birth, the nurse should assess the abdomen for softness. A hard, "guarded" abdomen is one of the first signs of peritonitis, a complication that may occur with any abdominal surgical procedure. Although important, breast filling does not lead to a life-threatening complication. Plans to breastfeed could have been determined prior to the cesarean birth. Because the baby was delivered through the abdomen, the perineum should not be edematous.

Question 2

A patient who had a previous cesarean birth asks the nurse if all future births must occur the same way. Which response should the nurse make to support the 2020 National Health Goals regarding cesarean births?

Accepted Answer

To fulfill the 2020 National Health Goals regarding cesarean births and answer the patient's question, the nurse should respond that patients who fulfill the criteria for vaginal birth after cesarean should attempt a vaginal birth with subsequent children. All future births do not need to be done through cesarean. The patient has a voice with deciding the type of birth that she would prefer with each pregnancy. Most women do not prefer cesarean births. This type of birth might not take as long; however, it is a painful surgical procedure.

Question 3

A patient whose fetus is presenting breech is scheduled to have a cesarean birth. What should the nurse anticipate this patient will need to ensure maximum postoperative care?

Accepted Answer

To reduce bladder size and keep the bladder away from the surgical field, an indwelling urinary catheter may be prescribed before transport for surgery or after arrival in the surgical suite. Because the bladder was handled and displaced during surgery, its tone or ability to sense filling may be inadequate to initiate voiding for the first postoperative day. For this reason, the indwelling catheter placed before surgery is usually left in place for 4 to 24 hours to ensure good urine drainage. The patient will not be on bed rest for 4 days after a cesarean birth. A nasogastric tube is not indicated for a cesarean birth. The infant will not be separated from the mother for 72 hours after a cesarean birth.

Question 4

A woman is scheduled to have epidural anesthesia for a cesarean birth. What should the nurse anticipate to include in the preoperative plan of care while the patient waits for the anesthetic?

Accepted Answer

The side-lying position helps prevent supine hypotension syndrome, and epidural anesthesia is usually administered with the patient lying on the side. Ambulation prior to anesthesia may or may not be indicated for the patient. Oral antacids and morphine sulfate are not a part of preparation for epidural anesthesia.

Question 5

A patient scheduled for a cesarean birth asks if there are any difficulties with breastfeeding after this type of delivery. What should the nurse include when responding to this patient?

Accepted Answer

The nurse can help the patient with breastfeeding by placing a pillow over the lap while the infant nurses. This position can deflect the weight of the infant from the suture line and lessen pain. The use of the football hold for breastfeeding is another way to keep the infant's weight off the incision. Breastfeeding is recommended after a cesarean birth. It is not difficult to find a comfortable position to hold a newborn to breastfeed. The patient will not have too much analgesia postoperatively for safe breastfeeding.

Question 6

A patient, preparing for patient-controlled analgesia for pain relief after a cesarean birth, asks if this is an effective way to control pain. What should the nurse respond to the patient?

Accepted Answer

With patient-controlled analgesia, a constant level of pain relief can be maintained, and pain and fear of injections are eliminated. This approach works well with postcesarean patients because the narcotic is injected in such small amounts; patients tend to use less analgesia with this approach than they would receive with intramuscular injections.
Breastfeeding is not contraindicated with patient-controlled analgesia. Patient-controlled analgesia has proven to be an effective method to control pain. Most patients like patient-controlled analgesia because they are able to control their own pain relief.

Question 7

A patient who has been in labor for 20 hours is being prepared for an emergent cesarean birth. Which action will help ensure the patient's fluid status during the procedure?

Accepted Answer

A patient who enters surgery with a lower than usual blood volume will experience the effect of surgical blood loss more than a patient who has a normal blood volume. A patient who has had a long labor before a cesarean birth is scheduled may fall into this category, because the patient may have had little to eat or drink for almost 24 hours.
Intravenous fluid replacement needs to be initiated preoperatively and continued postoperatively to prevent a serious fluid or electrolyte imbalance. Since surgery is imminent, the patient should be kept at "nothing by mouth" status, which means no ice chips or clear liquids. An antiemetic is not indicated for the patient at this time.

Question 8

Following a cesarean birth, a patient is prescribed to receive intravenous fluids. At which time should the nurse anticipate that this patient will be able to resume an oral intake?

Accepted Answer

Patients are kept at "nothing by mouth" status for a period of time after surgery until intestinal peristalsis has returned. To establish this is returning, the patient's abdomen should be assessed at least once every 8 hours for bowel sounds because this demonstrates air and fluid are moving through the intestines. As soon as bowel sounds return, IV fluid therapy is usually discontinued and the patient can slowly begin oral intake with fluids. Oral intake may or may not be permitted 24 to 48 hours after the procedure. Oral intake is not contingent on bladder tone.

Question 9

The nurse encourages a patient recovering from a cesarean birth to begin early ambulation. For which outcome would this action be indicated?

Accepted Answer

Early ambulation is an intervention to avoid lower extremity circulatory problems such as thrombophlebitis. Early ambulation is not an intervention to improve tolerance for clear liquids, prevent wound infection, or have success with breastfeeding.

Question 10

The fetus of a patient who is 30 weeks pregnant is failing to thrive in utero. The health care provider wants to deliver the fetus through cesarean birth today. The patient asks why this approach is preferred over a vaginal delivery. What should the nurse respond to the patient?

Accepted Answer

A cesarean delivery may be advantageous for a preterm birth to avoid pressure on the fetal head. A cesarean birth does not reduce the amount of postpartum pain. The health care provider does not want to use a cesarean birth because it is more convenient. A cesarean birth does not necessarily allow the placenta to deliver easier.

Question 11

A patient having a cesarean birth will have a low segment incision. What should the nurse explain to the patient as an advantage for this type of incision?

Accepted Answer

Because a low segment incision is through the nonactive portion of the uterus, it is less likely to rupture in subsequent labors, making it possible for a woman to have a vaginal birth after cesarean with a future pregnancy. This type of incision is not vertical. The cervix is not cut with this type of incision. This type of incision has no impact on the ability to resuscitate the infant if necessary.

Question 12

After learning about the need for a cesarean birth, the pregnant patient begins to cry and hyperventilate. Which nursing diagnosis should the nurse use to guide the care that the patient needs at this time?

Accepted Answer

The patient's emotional response after learning about a cesarean birth is most likely fear. The nurse should use the diagnosis of "fear related to impending surgery" to guide interventions at this time. The patient's emotional response is not likely because of a risk of infection, powerlessness, or a risk for impaired parent/infant attachment.

Question 13

The nurse assists while a pregnant patient has an amniotomy. Which action should the nurse take immediately at the conclusion of the procedure?

Accepted Answer

Amniotomy is the artificial rupturing of membranes during labor. A disadvantage of amniotomy is it puts a fetus momentarily at risk for cord prolapse if a loop of cord escapes into the vagina with the fluid. Always measure the fetal heart rate immediately after the rupture of membranes to determine this did not occur. The nurse can assist the patient with washing and applying a clean gown and linens after the fetal heart rate is assessed. The patient may or may not have an intravenous infusion at this time.

Question 14

The nurse is concerned that a pregnant patient will have a complication from a medication after a cesarean birth. For which prescribed medications are complications most likely to occur? (Select all that apply.)

Accepted Answer

Some medications can cause complications with cesarean births. Insulin may lead to hypoglycemia during labor or hyperglycemia if a dextrose solution is provided. Anticoagulants may cause hemorrhage due to lack of hemostasis during surgery. Antihypertensives may result in hypotension after anesthesia. Antianxiety agents may cause hypotension after anesthesia. There is no evidence to suggest that beta₂-adrenergic blockers will cause a complication after a cesarean birth.

Question 15

The nurse is preparing a teaching plan for a patient recovering from a cesarean birth. What should the nurse instruct the patient to help improve stamina and energy after the procedure?

Accepted Answer

To help a patient recovering from a cesarean birth regain stamina and energy, the nurse should instruct the patient to drink at least six glasses of fluid each day and rest twice a day for at least one-half hour each time. There is no limit to social events; however, the patient should not be expected to be a social hostess during this time. The amount of weight lifted should be restricted to the weight of the new baby and not increased each day. The patient should accept help from family and friends for house cleaning and shopping. The patient should not structure the day so that these activities are completed.

Quiz 24: Nursing Care of a Family During a Surgical Intervention for Birth