Chapter 11 - Intrapartum and Postpartum Care of Cesarean Birth Families

Question 11. The nurse is providing discharge instructions to a client and family following a cesarean section delivery three days ago. The family is unsure how to help the client at home. What does the nurse include in the education? Select all that apply. 1. Bring meals to the family. 2. Do not visit for three weeks. 3. Take infant for a walk each day. 4. Offer to do housework. 5. Feed the infant for the mother.

Ans: 1,4 Option 1: Bringing meals and offering to do housework can be beneficial to the new parents and allows for the mother to recover from surgery and reserve energy for caring for the newborn. Option 2: New parents often welcome visitors, and family can also be of great help during the time of recovery. Option 3: While this may be a possibility, it is best if family plans to assist with activities that are not baby related and allow the mother to care for the infant. Option 4: Bringing meals and offering to do housework can be beneficial to the new parents and allows for the mother to recover from surgery and reserve energy for caring for the newborn. Option 5: It is best if the family helps with other tasks and allows the parents to care for the infant to facilitate bonding.

Question 8. The nurse calls the provider on a cesarean section client the day after surgery to report concerns about peristaltic ileus. What assessment data does the nurse include in the report to the provider to support this concern? 1. Foul smelling discharge from the incision 2. Absent bowel sounds in the lower right quadrant 3. Temperature of 101.3℉ and 102.1℉ and hour later 4. Redness, pain, and swelling in the left calf

Ans: 2 Option 1: Foul smelling discharge from the incision would be indicative of an infection in the c-section incision. Option 2: A peristaltic ileus occurs from an absence of movement in the bowel and can result in an obstruction. The absence of peristalsis will result in an absence of bowel sounds. Option 3: Persistent fever would be concerning to an infective process somewhere in the body. Option 4: Redness, pain, and swelling in the leg would be a concern for symptoms of a deep vein thrombosis.

Question 10. The nurse is providing education to a client on when the Intravenous Catheter can be discontinued following a cesarean section. What information will the nurse include? 1. Client has adequate pain control with oral medication. 2. Client can maintain oral hydration without nausea. 3. Client has active bowel sounds in all four quadrants. 4. Client is breastfeeding infant well every couple of hours.

Ans: 2 Option 1: There are other methods of pain management beyond oral or IV, and this is generally not the key consideration in determining when the IV can be discontinued. Option 2: The client must be able to maintain hydration without the use of IV fluids. Option 3: This is an important consideration after surgery but does not impact the discontinuation of the IV. Option 4: This is an important consideration after delivery of a newborn, however it does not impact the IV discontinuation.

Question 4. The anesthesiologist reviews the blood work for a client scheduled for a cesarean section and determines that an epidural or spinal anesthesia are not possible. The nurse explains which lab result to the client as the reason for this determination? 1. White blood cell 9.8 th/mm3 2. Platelet 99 th/mm3 3. Hemoglobin 12.7 g/dL 4. Red blood cell 5.1 mil/mm3

Ans: 2 Option 1: This is a normal white blood cell count. Option 2: Platelets should be above 130 th/mm3. Low platelets are a contraindication for epidural. Option 3: This is a borderline hemoglobin and does not impact the use of spinal or epidural anesthesia. Option 4: This is a normal red blood cell count.

Question 1. During a scheduled cesarean section for placenta accreta, the client required a hysterectomy due to failure of the placenta to separate. The gravida 1 para 1 client delivered a healthy baby boy. What concern does the nurse anticipate addressing with the client? 1. Family dysfunction 2. Postpartum psychosis 3. Postpartum depression 4. Ineffective bonding

Ans: 3 Option 1: Family is not mentioned in this question and does not appear to be a concern with the client at this time. Option 2: Psychosis is a severe disorder, and there are no indications that this would be a concern for this client. Option 3: Postpartum depression is a risk factor for complicated deliveries, and this client also lost the ability to bare more children, increasing the concern further. Option 4: While bonding could be compromised, it is due to the postpartum depression.

Question 13. While preparing for a cesarean section delivery, a client asks the nurse when she will be able to ambulate following the surgery. What information will the nurse share with the client? 1. Three hours after the surgery 2. After partial return of sensation 3. After complete return of sensation 4. Twenty-four hours after the surgery

Ans: 3 Option 1: Following anesthesia, the client must wait until complete return of sensation in the lower extremities before ambulating. This is usually around 6-12 hours. Option 2: Following anesthesia, the client must wait until complete return of sensation in the lower extremities before ambulating. This is usually around 6-12 hours. Option 3: Following anesthesia, the client must wait until complete return of sensation occurs in the lower extremities before ambulating. This is usually around 6-12 hours. Option 4: Following anesthesia, the client must wait until complete return of sensation in the lower extremities before ambulating. This is usually around 6-12 hours.

Question 3. When an emergency cesarean section is required a guideline is set for a time frame surrounding the decision time to the incision time. The nurse explains to the client the guidelines for time to optimize fetal outcomes. What timeframe does the nurse share with the client? 1. 60 minutes 2. 45 minutes 3. 30 minutes 4. 15 minutes

Ans: 3 Option 1: The guidelines for decision to incision are 30 minutes. Option 2: The guidelines for decision to incision are 30 minutes. Option 3: The guidelines for decision to incision are 30 minutes. Option 4: The guidelines for decision to incision are 30 minutes.

Question 17. The nurse is preparing a client for a scheduled cesarean section for a breech presentation and a failed external cephalic version. The couple has two other children at home. What statement made by the client during the admission would require intervention by the nurse? 1. "My mother is coming to stay with us for a couple weeks. She will be helping with housework." 2. "I am disappointed with having to have a c-section, but am glad to finally meet my new son today." 3. "It is a relief to know my partner can stay in the room with me during the surgery." 4. "I will miss being able to breastfeed. I breastfed my other children for one year ea

Ans: 4 Option 1: Having help during the recovery period following surgery is quite beneficial to a new mother. Option 2: Disappointment is a normal feeling and is not concerning when partnered with happiness. Option 3: Support from the partner can make the c-section process less scary for the client. Option 4: Women can breastfeed following surgery. The nurse would want to discuss positions that would be more comfortable due to the incision.

Question 12. A new nurse is providing discharge instructions to a client who is going home three days after a cesarean section delivery. The charge nurse walks by the room and overhears the nurse giving the instructions. Which information would require intervention by the charge nurse? 1. "You will want to continue pain medication as needed to manage the pain." 2. "The baby will need to follow up with the pediatrician in a couple days." 3. "You should try to rest when the baby is resting to help with recovery." 4. "You can remove the staples at home tomorrow utilizing this staple remover."

Ans: 4 Option 1: Pain medication will likely be needed following discharge from a c-section delivery. Option 2: It is common for the infant to see the provider shortly after discharge from the hospital. Option 3: Any new parent should rest while the infant is resting. Option 4: The client should never remove their own staples. If the staples have not been removed before discharge, the client should be seen in the provider's office for removal.

Question 6. Following the occurrence of several cesarean sections, the charge nurse is reviewing the blood loss on four clients. What is the expected maximum value of blood loss for a client who underwent a cesarean section? 1. 750 mL 2. 825 mL 3. 950 mL 4. 1000 mL

Ans: 4 Option 1: The maximum amount of blood loss for a c-section client is 1000 mL. Option 2: The maximum amount of blood loss for a c-section client is 1000 mL. Option 3: The maximum amount of blood loss for a c-section client is 1000 mL. Option 4: The maximum amount of blood loss for a c-section client is 1000 mL.

Question 14. A client is requiring a rubella vaccination before discharge following cesarean section delivery of a 34-week gestation female infant. The infant is in the Neonatal Intensive Care Unit. The nurse is explaining why the immunization is required. What should be included in the explanation? 1. Rubella vaccine is given to parents of premature infants. 2. The mother must not have been vaccinated as a child. 3. The mother's blood work demonstrated a non-immune status. 4. This is a normal booster vaccine given to all adults.

Ans:3 Option 1: During pregnancy, women have bloodwork done that includes a titer to evaluate immunity to rubella. If the client is found to be non-immune, rubella vaccination is given prior to discharge after the delivery of the infant. Option 2: During pregnancy, women have bloodwork done that includes a titer to evaluate immunity to rubella. If the client is found to be non-immune, rubella vaccination is given prior to discharge after the delivery of the infant. Option 3: During pregnancy, women have bloodwork done that includes a titer to evaluate immunity to rubella. If the client is found to be non-immune, rubella vaccination is given prior to discharge after the delivery of the infant. Option 4: During pregnancy, women have bloodwork done that includes a titer to evaluate immunity to rubella. If the client is found to be non-immune, rubella vaccination is given prior to discharge after the delivery of the infant.

Question 9. Following a cesarean section, a client with asthma is concerned with developing post-operative pneumonia. What will the nurse include in the education on preventative measures during the first 12 hours after surgery? Select all that apply. 1. Assessing lungs every four hours 2. Utilizing the incentive spirometer regularly. 3. Encourage cough and deep breathing regularly. 4. Ambulate within 24 hours of surgery. 5. Use oxygen when lying in bed.

Ans; 2,3 Option 1: Assessing the lungs is important, however it does not prevent pneumonia. Option 2: Incentive spirometry, along with cough and deep breathing, encourages the client to fully expand the lungs and helps to prevent pneumonia. Option 3: Incentive spirometry, along with cough and deep breathing, encourages the client to fully expand the lungs and helps to prevent pneumonia. Option 4: Ambulation after surgery is important, however this is not a direct preventative measure for pneumonia. Option 5: The use of oxygen may be indicated for respiratory depression but is not a preventative measure for pneumonia.

Question 5. The nurse is preparing a client for a cesarean section who is scheduled for 0900. What time will the nurse administer cefazolin? 1. 07:30 2. 08:55 3. 08:00 4. 07:00

Ans; 3 Option 1: Prophylactic antibiotics should be administered one hour before the time of the c-section. Option 2: Prophylactic antibiotics should be administered one hour before the time of the c-section. Option 3: Prophylactic antibiotics should be administered one hour before the time of the c-section. Option 4: Prophylactic antibiotics should be administered one hour before the time of the c-section.

Question 50. Following a cesarean section a few hours ago, the partner of a client comes out to the nurses' station to report severe itchiness the client is experiencing. The partner voices concern that the client is experiencing an allergic reaction to the morphine given during surgery. How does the nurse respond to the client when entering to the room to assess the itching? 1. "Itchiness, also known as pruritis, is a common reaction to morphine and is not considered an allergy." 2. "Here is some medication to stop the itching." 3. "I will note in your medical record that you have an allergy to morphine." 4. "Let me call the provider and report the itching."

ans 1 Option 1: Pruritus is a common side effect to morphine and is not considered an allergic reaction. Diphenhydramine may be given if the client is very uncomfortable. This would be considered a drug intolerance. Option 2: While the client could receive diphenhydramine, this response does not address the client's concern about an allergic reaction. Option 3: Pruritus is a side effect from morphine and would not be considered an allergy. Option 4: Since pruritus is an anticipated side effect of morphine, calling the provider would not be necessary.

Question 41. A client who had a cesarean section calls to the nurses' station and requests the nurse to come to the room two hours after the foley catheter was removed. The client asks the nurse to check for increased vaginal bleeding, due to a feeling of a gush of blood. The nurse notes a large amount of blood, and upon palpation notes that the uterus is displaced to the right and the fundus is boggy. What is the priority intervention the nurse will provide to the client? 1. Retrieve bedpan to allow for client to attempt to empty bladder 2. Administer oxytocin intramuscularly per order 3. Massage the uterus until a return to a midline position and firm 4. Administer a bolus of IV fluids due to the increased bleeding

ans 1 Option 1: The most common cause of a displaced uterus following delivery is a full bladder, emptying the bladder will allow for the uterus to contract appropriately and bleeding to decrease. Option 2: Emptying the bladder would be the first intervention for this client. Medication would be given only if indicated following other interventions. Option 3: Without emptying the bladder, the uterus would not return to a midline position. Option 4: A bolus of fluids would not help to control the bleeding.

Question 44. The operating room nurse is ready to conduct the "time out" process before the start of the cesarean section on a client. What will the operating room staff confirm during this process? Select all that apply. 1. Right patient 2. Right procedure 3. Right time 4. Right gestation 5. Right site

ans 1,2,5 Option 1: The components of the "time out" process should include the right site, right procedure, and the right patient. Option 2: The components of the "time out" process should include the right site, right procedure, and the right patient. Option 3: The right time is not a component of the "time out" process, as time can change for surgery. Option 4: While it may be important to consider gestational age for repeat c-sections, it is not a component of the "time out" process. Option 5: The components of the "time out" process should include the right site, right procedure, and the right patient.

Question 37. During a childbirth education class focused on labor and delivery, the nurse is discussing Cesarean Delivery on Maternal Request. What neonatal complications does the nurse include when addressing deliveries earlier then 39 weeks' gestation? Select all that apply. 1. Respiratory distress 2. Hypothermia 3. Hysterectomy 4. Feeding intolerance 5. Hypoglycemia

ans 1,2,5 Option 1: Preterm infants are at risk for respiratory distress, hypothermia, hypoglycemia, and NICU admission. Option 2: Preterm infants are at risk for respiratory distress, hypothermia, hypoglycemia, and NICU admission. Option 3: While hysterectomy is a risk with repeated c-sections, it is not a neonatal complication. Option 4: Feeding intolerance is a possibility in preterm infants but varies tremendously by gestational age at delivery. Option 5: Preterm infants are at risk for respiratory distress, hypothermia, hypoglycemia, and NICU admission.

Question 38. The nurse is preparing a client in the operating room for a cesarean section. The client asks the nurse why a roll is being placed under the hip. How should the nurse respond? 1. "The hip tilt position allows the provider easier access to the uterus for delivery." 2. "The hip tilt position eases pressure on the inferior vena cava and decreases the risk of hypotension." 3. "The hip tilt position decreases bladder distention and reduces the risk of bladder injury during surgery." 4. "The hip tilt position allows for a quicker delivery of the infant during the c-section."

ans 2 Option 1: The hip tilt position is utilized to decrease the pressure on the inferior vena cava, reducing maternal hypotension and subsequent fetal intolerance. While other benefits may result from this position, they are not the reasoning for such. Option 2: The hip tilt position is utilized to decrease the pressure on the inferior vena cava, reducing maternal hypotension and subsequent fetal intolerance. While other benefits may result from this position, they are not the reasoning for such. Option 3: The hip tilt position is utilized to decrease the pressure on the inferior vena cava, reducing maternal hypotension and subsequent fetal intolerance. While other benefits may result from this position, they are not the reasoning for such. Option 4: The hip tilt position is utilized to decrease the pressure on the inferior vena cava, reducing maternal hypotension and subsequent fetal intolerance. While other benefits may result from this position, they are not the reasoning for such.

Question 49. A mother-baby nurse just received report on four mother baby couplets and is preparing to start the first assessments of the shift. All are recovering from cesarean section deliveries. Which couplet will need to be seen first? 1. Couplet #1: the infant and mother have been doing well since delivery 3 days ago and would like to be discharged in the next couple hours. 2. Couplet #2: the infant has been breastfeeding successfully and the mother has required the uterine fundus to be massaged to firm. 3. Couplet #3: the mother has chosen to bottle feed the infant, and the infant has lost 89 grams of the 3200-gram birth weight at 2 days of age 4. Couplet #4: the infant has been experiencing difficulties latching on to breastfeed and last nursed successfully an hour and a half ago.

ans 2 Option 1: While discharge is important, there is nothing in this information to identify an urgent need for assessment. Option 2: When the fundus requires massage to firm up, there is a need for close follow up and monitoring of blood loss to assess for postpartum hemorrhage. Option 3: The weight loss of this infant is only 2.7% at this time and is well within normal limits, so no urgency in assessment of this couplet. Option 4: While there may be concern with assisting with breastfeeding, a newborn should breastfeed every 2-3 hours, so this infant does not require immediate assessment.

Question 48. Following cesarean delivery, a stable female infant weighing 3,126 grams is placed skin-to-skin with the mother. The client's partner asks why the infant is placed with the mother during the remainder of the surgery. What is the best response from the nurse? 1. "Placing the infant with the mother reduces the need to have another nurse in the crowded operating room." 2. "We can discuss this later, I need to help the surgeon right now." 3. "Infants are less likely to need NICU care when placed skin-to-skin with the mother." 4. "It is important to get a picture immediately after delivery of the infant."

ans 3 Option 1: Best practice ensures there is a neonatal nurse, nurse practitioner or neonatologist for the infant in the operating room. Option 2: It is always best to answer the client's question when asked. Option 3: Research has demonstrated a reduction in NICU observation in cesarean delivery infants when placed skin-to-skin with the mother. Option 4: While pictures are important to the family, this is not a reason to utilize skin-to-skin after delivery.

Question 45. A provider has determined a client needs a cesarean section for cephalopelvic disproportion. The client asks the nurse to explain what cephalopelvic disproportion means. What is the best response by the nurse? 1. "You are needing a c-section due to the baby experiencing stress from labor." 2. "Let's focus on preparing for the surgery." 3. "The baby is too large for your pelvis." 4. "Have you had a recent ultrasound to estimate the baby's weight?"

ans 3 Option 1: Cephalopelvic disproportion relates to the size of the infant and the size of the maternal pelvis. Option 2: Answering the client's questions is always better than changing the subject. Option 3: Cephalopelvic disproportion relates to the size of the infant and the size of the maternal pelvis. Option 4: The size of the infant does impact the cephalopelvic disproportion; however, this information does not answer the client's question.

Question 42. The nurse is scheduling a client for pre-operative blood work prior to a scheduled repeat cesarean section next week. The client is very concerned about needing more bloodwork drawn. How should the nurse respond to the client's concern? 1. "The provider would order bloodwork even if you were having a vaginal delivery." 2. "You need to get this done, or anesthesia will not allow for the surgery to occur." 3. "The bloodwork helps the provider to identify potential risk factors that could complicate the surgery." 4. "Just take your husband with you to help you stay calm while getting the blood drawn."

ans 3 Option 1: Often bloodwork is done for a vaginal delivery as well, however this response does not address the concern. Option 2: While anesthesia will want the results, this response only offers a limited explanation and is not therapeutic. Option 3: This response addresses the client concern and is therapeutic in nature. Option 4: This response may not be sensitive to the client's needs, as the nurse assumed the client was married to a male.

Question 36. The nurse is scheduling a client for pre-operative blood work prior to a scheduled repeat cesarean section next week. The client is very concerned about needing more bloodwork. How does the nurse respond to the client's concern? 1. "The provider would order bloodwork even if you were having a vaginal delivery." 2. "You need to get this done or anesthesia will not allow for the surgery to occur." 3. "The bloodwork helps the provider to identify potential risk factors that could complicate the surgery." 4. "Just take your husband with you to help you stay calm while getting the blood drawn."

ans 3 Option 1: Often bloodwork is done for a vaginal delivery as well, however this response does not address the concern. Option 2: While anesthesia will want the results, this response only offers a limited explanation and is not therapeutic. Option 3: This response addresses the client's concern and is therapeutic in nature. Option 4: This response may not be sensitive to the client's needs, as the nurse assumed the client was married—specifically married to a male.

Question 39. A client calls for the nurse to come to the room the day after a cesarean section delivery. Upon arrival to the client's room, the nurse notes that the client is dyspneic and appears short of breath. The client reports that her chest feels tight. Based on these assessment findings, what does the nurse report to the provider? 1. Postpartum hemorrhage 2. Wound infection 3. Pulmonary embolism 4. Wound dehiscence

ans 3 Option 1: Postpartum hemorrhage would present with circulatory symptoms initially, including increased pulse rate and decreased blood pressure. Option 2: Wound infection would present with fever, as well as redness and warmth at the incision site. Option 3: Pulmonary embolism would present with respiratory symptoms, including chest tightness, dyspnea, and shortness of breath. Option 4: Wound dehiscence would present with separation of the surgical incision.

Question 53. A nurse is completing an assessment on a client following a cesarean section delivery the day before. The client appears to be short of breath. Vital signs are as follows: Temperature 98.5?, Pulse 62, Respirations 42, Blood pressure 102/74, and Pulse oximetry 88%. Based on these assessment findings, what concern does the nurse relay to the provider? 1. Uterine infection 2. Postpartum hemorrhage 3. Pulmonary embolism 4. Disseminated intravascular coagulation

ans 3 Option 1: Uterine infection is at an increased risk following delivery by c-section, however the vital signs are not concerning for this complication. Option 2: Postpartum hemorrhage can occur after a c-section delivery; however, this complication is not a concern with the vital signs that are present. Option 3: Pulmonary embolism risk is increased following surgery, and the shortness of breath, tachypnea, and decreased oxygen saturation are consistent with this complication. Option 4: Disseminated intravascular coagulation is a risk that can occur and can result from postpartum hemorrhage.

Question 46. The obstetric nurse is preparing a client for an epidural. What is the priority nursing intervention prior to this procedure? 1. Monitor fetal heart tones 2. Obtain maternal blood pressure 3. Administer IV fluid bolus 4. Assess for prior epidural anesthesia

ans 3 Option 1: While monitoring fetal heart tones is important, this intervention does not avoid adverse reactions. Option 2: Obtaining the maternal blood pressure is important, but does not prevent an adverse reaction. Option 3: The most common reaction to epidural anesthesia is hypotension, so a fluid bolus before is important to prevent this complication. Option 4: There is no impact of prior anesthesia on prevention of hypotension.

Question 40. Upon entering a client room to perform the initial assessment following a cesarean section, the nurse finds the client tearful and the client's partner mentions mutual disappointment with the unexpected c-section delivery, as they had desired a natural birth. How does the nurse respond to the couple? 1. "Since the baby is healthy, you should be happy." 2. "C-sections happen all the time, there is nothing to cry about." 3. "Tell me more about how you are feeling after the surgery." 4. "Maybe next time you can delivery vaginally."

ans 3 Option 1: While this is a common response, it does not address the couple's disappointment, but rather dismisses their emotions. Option 2: This response is not therapeutic and dismisses the client's emotions. Option 3: This response demonstrates the nurse's willingness to actively listen to the couple's concerns and feelings surrounding the unexpected surgery. Option 4: While there is potential for the client to attempt a trial of labor after cesarean with the next pregnancy, it diminishes the current disappointment the couple is

Question 51. The nurse is assessing client 12 hours post cesarean section delivery, of a healthy male infant weighing 9 pounds 3 ounces. The client's Foley catheter was removed three hours ago. Which subjective assessment data requires immediate intervention? 1. The client reports pain at a level of four and can tolerate a five. 2. The client reports the infant nursed for about 20 minutes one and a half hours ago. 3. The client has a blood pressure of 92/48. 4. The client reports no voiding since the catheter was removed.

ans 4 Option 1: Pain within the client's acceptable tolerance level does not require intervention. Option 2: Newborns should nurse every two to three hours, so this requires no intervention at this time. Option 3: While this blood pressure is on the low side, it is an objective finding and also could be normal for the client. Option 4: This finding requires immediate assessment for bladder distention. A distended bladder can contribute to uterine atony.

Question 20. A nurse on the postpartum care unit is anticipating admission of a client immediately after an emergency cesarean section. The surgery was due to a Category III fetal monitor tracing and was performed under general anesthesia. What client concerns does the nurse anticipate as addressing with this client? 1. The need for the C-section delivery 2. The frequency of vital signs 3. The need to bottle feed the infant 4. The type of delivery for future pregnancies

ans :1 Option 1: Often in an emergency C-section, the client and partner have many questions regarding the situation following delivery. Addressing these concerns is important to decrease anxiety for the client. Option 2: While the frequency of vital signs is important, the client's anxiety may alter these and should be addressed. Option 3: A C-section delivery does not result in a need to bottle feed the infant. Option 4: While this may come up with some parents, this would not be an anticipated need immediately following the surgery.

Question 31. The nurse is preparing a client for a cesarean section. Following the epidural anesthesia, the nurse is ready to show the partner where to stay during the surgery. Where does the nurse show the partner to go? 1. On a stool next to the client's head. 2. On a stool next to the infant warmer. 3. In a waiting room next to the operating room. 4. In the recovery room, to await completion of the surgery.

ans :1 Option 1: The placement on the stool allows for the partner to be with the client throughout the surgery, but also to remain in a seated position in case of fainting. Option 2: The partner will remain with the client, and the infant would be brought to the client. Option 3: The partner will remain in the Operating Room with the client and infant. Option 4: The partner will remain in the Operating Room with the client and infant.

Question 26. Following completion of four deliveries via cesarean section, the nurse states in shift report the APGAR scores for the four newborns. Which infant does the oncoming nurse see first? 1. APGAR 5, APGAR 7 2. APGAR 8, APGAR 8 3. APGAR 9, APGAR 10 4. APGAR 7, APGAR 9

ans: 1 Option 1: APGAR scores are expected to be 7 or above at one and five minutes following delivery, unless there is fetal intolerance to labor prior to delivery. Option 2: APGAR scores are expected to be 7 or above at one and five minutes following delivery, unless there is fetal intolerance to labor prior to delivery. Option 3: APGAR scores are expected to be 7 or above at one and five minutes following delivery, unless there is fetal intolerance to labor prior to delivery. Option 4: APGAR scores are expected to be 7 or above at one and five minutes following delivery, unless there is fetal intolerance to labor prior to delivery.

Question 27. A nurse is caring for a client following a cesarean section delivery the day before. During the assessment, the nurse checks for Homan's sign. Why is the nurse conducting this assessment? 1. There is an increased risk of thromboembolism after surgery. 2. This assessment checks for wound healing on the surgery site. 3. It is important to check for peripheral circulation following surgery. 4. Constipation is a risk after a cesarean delivery.

ans: 1 Option 1: Homan's sign looks for pain in the calf with dorsiflexion and a positive result is concerning for a deep vein thrombosis. Option 2: Homan's sign looks for pain in the calf with dorsiflexion and a positive result is concerning for a deep vein thrombosis. Option 3: Homan's sign looks for pain in the calf with dorsiflexion and a positive result is concerning for a deep vein thrombosis. Option 4: Homan's sign looks for pain in the calf with dorsiflexion and a positive result is concerning for a deep vein thrombosis.

Question 29. A client is pregnant with her second child following a cesarean section delivery with the first pregnancy for a breech fetal position. The couple plans to have three children total. What option does the nurse discuss as the best one for this couple? 1. Vaginal birth 2. Repeat c-section 3. External cephalic version 4. Only having two children

ans: 1 Option 1: When a family plans more than two children, it is best to have no more than two c-sections. So an attempt at vaginal birth would be the best option for the couple. Option 2: When a family plans more than two children, it is best to have no more than two c-sections. So an attempt at vaginal birth would be the best option for the couple. Option 3: External cephalic version is conducted when the fetus is in a breech position. There is no indication that the fetus is breech. Option 4: Honoring the client's wishes is always best. It would be inappropriate for the nurse to suggest the client have fewer children.

Question 54. The nurse is performing preoperative care on a client scheduled for cesarean section. Which nursing actions should be performed? Select all that apply. 1. Insert an IV catheter 2. Administer sodium citrate 3. Trim pubic hair 4. Insert straight catheter 5. Apply sequential compression devices

ans: 1,2,3,5 Option 1: IV fluids are given during surgery, so starting the IV before is required. Option 2: Sodium citrate is administered before the surgery to neutralize stomach acids. Option 3: Pubic hair is trimmed to allow for better visualization of the incision site. Option 4: A foley catheter is utilized for surgery, as opposed to a straight catheter, to allow for continual draining of the bladder. This allows for the bladder to not obscure the surgery field. Option 5: Sequential compression devices, or SCD, are used as prophylaxis for thrombosis and are applied prior to surgery.

Question 43. The nurse is assessing a client's incision following a cesarean section. The dressing has just been removed. What findings would require further intervention? Select all that apply. 1. Ecchymosis 2. Warmth 3. Edema 4. Approximation 5. Redness

ans: 1,2,3,5 Option 1: The abdominal incision should be clean, intact, approximated, and free of redness, edema, ecchymosis, and drainage. Option 2: The abdominal incision should be clean, intact, approximated, and free of redness, edema, ecchymosis, and drainage. Warmth would be an indicator of infection. Option 3: The abdominal incision should be clean, intact, approximated, and free of redness, edema, ecchymosis, and drainage. Option 4: The abdominal incision should be clean, intact, approximated, and free of redness, edema, ecchymosis, and drainage. Option 5: The abdominal incision should be clean, intact, approximated, and free of redness, edema, ecchymosis, and drainage.

Question 28. While presenting an educational session on childbirth the nurse was asked to discuss risk factors requiring a cesarean section. What should the nurse include in her response? Select all that apply. 1. Advanced maternal age 2. Spontaneous labor onset 3. Breech position 4. Maternal request 5. Multiparit

ans: 1,3 Option 1: Over half of c-sections are performed in women over 40 years of age. Option 2: C-section risk is increased for induction of labor, but not spontaneous labor onset. Option 3: Breech positioning is a risk factor for c-sections, as this makes vaginal delivery more challenging. Option 4: Maternal request can be a reason for a c-section, however this is not a risk factor. Option 5: Nulliparous women, particularly with induction are more at risk than multiparous women.

Question 33. A nurse is preparing to assist a new mother with breastfeeding following a cesarean section delivery. Which positions will the nurse recommend to maximize patient comfort while breastfeeding? Select all that apply. 1. Side-lying position 2. Cradle hold 3. C-cup positioning 4. Using a breast pump 5. Football hold

ans: 1,5 Option 1: A side-lying position decreases pressure on the incision, allowing for increased maternal comfort during breastfeeding following a cesarean section. Option 2: While the cradle hold is considered a typical breastfeeding position, it does not alleviate pressure form the incision, and is not going to improve comfort for the mother. Option 3: During all breastfeeding sessions, the mother should utilize a c-hold to position the breast for the feeding. Option 4: At times a breast pump may be needed at times following a c-section, however it does not increase comfort. Option 5: The football hold decreases direct pressure on the c-section incision, increases comfort for the mother.

Question 21. A new labor and delivery nurse is working with a preceptor to prepare a client for a cesarean section delivery. There is a fetal scalp electrode in place to monitor the fetal heart rate. When does the preceptor advise the new nurse to remove the scalp electrode? 1. Right after the infant is delivered during the surgery 2. After the abdominal prep for surgery 3. Prior to placement of the epidural anesthesia 4. Prior to transfer to the operating room

ans: 2 Option 1: The scalp electrode must be removed prior to delivery of the infant. Option 2: The scalp electrode will be removed after the anesthesia is done and the abdomen is prepped, but before the incision is made. Option 3: The scalp electrode should be in place throughout anesthesia placement and long enough for fetal assessment following anesthesia placement. Option 4: The scalp electrode will need to remain in place for fetal monitoring in the operating room prior to the start of surgery.

Question 22. The nurse is caring for a client who delivered a nulliparous pregnancy via cesarean section late the day before. The client is requesting eggs for breakfast. The grandmother is concerned with the client eating a regular diet so soon after surgery. How does the nurse respond to the concern? 1. "That is not how we do it anymore." 2. "Eating actually helps with return of bowel function." 3. "Research changes how things are done frequently." 4. "It is best to always give the client what they want."

ans: 2 Option 1: This is not a therapeutic response to the family member. Option 2: Recent research has demonstrated that early diet advancement leads to sooner return of bowel function. Option 3: While research does change, this response does not address the concern of the family member. Option 4: While the client's request is always considered, always is a very strong word.

Question 35. A nurse is caring for a client following a cesarean section four hours ago that occurred due to arrest of labor. Initially, the client was admitted to the hospital two days ago after experiencing spontaneous rupture of membranes. Which medication order does the nurse anticipate for this client? 1. Bisacodyl 2. Ampicillin 3. Methergine 4. Dexamethasone

ans: 2 Option 1: While a laxative may be ordered, this is not an anticipated order given the information offered. Option 2: Women who experience prolonged rupture of membranes (>24 hours) will require antibiotic treatment Option 3: This medication is used to control bleeding in clients experiencing postpartum hemorrhage Option 4: This is a corticosteroid that is administered to mother's in anticipation of premature delivery, as it helps with fetal lung maturity.

Question 34. While assessing a post-operative cesarean section client, the nurse notes a temperature of 102.1?. Prior to calling the provider, what other assessment should the nurse complete to include when reporting the concern? 1. Identify the time of last pain medication 2. Assess the c-section incision 3. Assess lung sounds and incentive spirometry 4. Assess uterine fundus and lochi

ans: 2 Option 1: While pain medication is important, this is not a priority to include when reporting a fever. Option 2: An infection in the incision could be a concern when the client presents with a fever, so the provider will need this information. Option 3: While it is important to assess respirations, this is not a priority at this time. Option 4: While this is also important information, the primary concern with a fever post c-section is the incision.

Question 19. The nurse is preparing to transport a client accompanied by her partner to the operating room for a cesarean section. The client wears eyeglasses that must be removed. Where should the nurse place the glasses? 1. In the nightstand drawer 2. With the partner 3. In the safe in the room 4. With the client

ans: 2 Option 1: While there are many safe areas to place the glasses in the client's room, it is best practice for the glasses to be placed with the partner. The partner can then provide the glasses to the client in the operating room following delivery of the infant. Option 2: While there are many safe areas to place the glasses in the client's room, it is best practice for the glasses to be placed with the partner. The partner can then provide the glasses to the client in the operating room following delivery of the infant. Option 3: While there are many safe areas to place the glasses in the client's room, it is best practice for the glasses to be placed with the partner. The partner can then provide the glasses to the client in the operating room following delivery of the infant. Option 4: The client should not have the glasses until after delivery due to the many movements while preparing for anesthesia and surgery.

Question 25. The charge nurse is reviewing documentation with a newly hired postpartum nurse. During review of the uterine fundus assessments, which client requires prompt intervention by the charge nurse? 1. Client #1 2. Client #2 3. Client #3 4. Client #4

ans: 3 Option 1: The finding on client #1 is a normal finding for the uterus following delivery. Option 2: While the uterus required massage to firm up, this can be normal and while follow up is required, this is not the most urgent need. Option 3: The fundus should be assessed in a c-section client to ensure firmness and monitor for uterine atony that could lead to a postpartum hemorrhage. Option 4: The finding on client #4 is a normal finding for the uterus following delivery.

Question 24. The provider is providing an emergency cesarean section and uses the following skin incision. How will the nurse document this type of incision? 1. Transverse 2. Pfannenstiel 3. Classical 4. Midline

ans: 3 Option 1: The transverse or pfannenstiel incision is a low horizontal incision. Option 2: The transverse or pfannenstiel incision is a low horizontal incision. Option 3: Classical refers to the vertical incision made on the abdomen. Option 4: Midline is not a term utilized to describe a c-section incision.

Question 18. A client reports a headache and dizziness following a scheduled cesarean section yesterday with spinal anesthesia. What does the nurse report to the provider as a concern for this client? 1. Migraine headache 2. Sinus infection 3. Vertigo 4. Spinal headache

ans: 4 Option 1: Following spinal anesthesia, a client can experience a spinal headache that results from a leakage of spinal fluid. Option 2: Following spinal anesthesia, a client can experience a spinal headache that results from a leakage of spinal fluid. Option 3: Following spinal anesthesia, a client can experience a spinal headache that results from a leakage of spinal fluid. Option 4: Following spinal anesthesia, a client can experience a spinal headache that results from a leakage of spinal fluid.

Question 30. Following a cesarean section, the nurse caring for the client notes the following assessment data: Temperature 99.1?, Heart rate 136, Respirations 20, Blood pressure 82/48, and skin pale and clammy to the touch. The nurse reports concern of what postpartum complication to the provider? 1. Respiratory depression 2. Renal failure 3. Wound infection 4. Postpartum hemorrhage

ans:4 Option 1: The respiratory rate is normal, thus eliminating this answer choice. Option 2: While renal failure could be a long-term result of postpartum hemorrhage, the immediate concern is hemorrhage. Option 3: While wound infection is a possibility after a cesarean section, the temperature is not of concern at this time. Option 4: Hemorrhage leads to symptoms of hypovolemic shock, including elevated pulse and decreased blood pressure.

Question 23. A nurse is completing an assessment on a client following a cesarean section the day before. The client appears short of breath and vital signs are as follows: Temperature 98.5?, Pulse 62, Respirations 42, Blood pressure 102/74, and Pulse oximetry 88%. What concern does the nurse relay to the provider? 1. Uterine infection 2. Postpartum hemorrhage 3. Pulmonary embolism 4. Disseminated intravascular coagulation

ans; 3 Option 1: Uterine infection is at an increased risk following delivery by C-section, however the vital signs are not concerning for this complication. Option 2: Postpartum hemorrhage can occur after a C-section delivery; however, this complication is not a concern with the vital signs that are present. Option 3: Pulmonary embolism risk is increased following surgery, and the shortness of breath, tachypnea, and decreased oxygen saturation are consistent with this complication. Option 4: Disseminated intravascular coagulation is a risk that can occur and can result from postpartum hemorrhage

Question 32. The nurse is calculating total estimated blood loss for an eight-hour shift on a client. The client is recovering from a c-section on the previous day. The nurse has documented the following weights for four pads during the shift: 153 g, 208 g, 92 g, and 346 g. What is the total estimated blood loss in mL for the client during the shift? Enter numerical value only.

799

Question 2. While preparing a client for an emergency cesarean section, the nurse places an oxygen mask on the client. What is the rationale for this nursing intervention? 1. Prevent hypertension 2. Prevent tachypnea 3. Decrease anxiety 4. Fetal intolerance to labor

Ans 4 Option 1: While the client may have hypertension as a result of increased anxiety, the use of oxygen is not to prevent this possibility. Option 2: Tachypnea may occur due to anxiety; however, the use of oxygen is not related to this possibility. Option 3: Anxiety would be anticipated due to the emergent nature of the surgery; however, oxygen is not used for that expected client response. Option 4: A common indication for c-section is fetal intolerance to labor, and when that occurs, oxygen is utilized to assist the fetus.

Question 15. A nurse is teaching a childbirth education class for expectant parents. One of the clients is concerned about cesarean sections and asks what the most common indication for needing a cesarean section would be. What is the appropriate nursing response? 1. Arrest of labor 2. Malpresentation 3. Multiple gestation 4. Preeclampsia

Ans: 1 Option 1: Arrest of labor accounts for 34% of c-section deliveries. Option 2: Malpresentation accounts for 17% of c-section deliveries. Option 3: Multiple gestation accounts for 7% of c-section deliveries. Option 4: Preeclampsia accounts for 3% of c-section deliveries.

Question 7. The nurse in the Post Anesthesia Care Unit is weighing pads to calculate blood loss following a cesarean section delivery. The nurse converts the grams of weight to milliliters of blood loss. What is the conversion formula that is used in this calculation? 1. 1 mL = 2 g 2. 2 mL = 1 g 3. 0.5 mL = 2 g 4. 1 mL = 1 g

Ans: 4 Option 1: The correct estimation of blood loss is based on a conversion of 1 gram equal to 1 milliliter of blood loss. Option 2: The correct estimation of blood loss is based on a conversion of 1 gram equal to 1 milliliter of blood loss. Option 3: The correct estimation of blood loss is based on a conversion of 1 gram equal to 1 milliliter of blood loss. Option 4: The correct estimation of blood loss is based on a conversion of 1 gram equal to 1 milliliter of blood loss.

Question 47. While the nurse is preparing a client for an emergency cesarean section, the family voices concern that the client is extremely nervous about the procedure. How does the nurse respond to the client? 1. "Tell me about how you are feeling right now." 2. "We do many c-sections every day, you will be fine." 3. "I am going to insert the foley catheter now." 4. "It is important that you try to calm down for the baby."

ans 1 Option 1: It is important to gain insight into how the client is feeling about the surgery, given the family's remarks. Option 2: This statement is not therapeutic to the client because it dismisses her fears and doesn't seek to gain insight into her feelings. Option 3: While this may be something that you will need to do, it does not consider the client's or her family's concerns. Option 4: This too is important, but does not help the client to work through the anxiety.

Question 16. During assessment of a cesarean section incision, the nurse notes some concerns and decides to call the provider to report the findings. What findings would indicate a need for further nursing intervention? Select all that apply. 1. Ecchymosis 2. Edematous 3. Approximated 4. Redness 5. Drainage free

Ans:1,2,4 Option 1: Ecchymosis, redness, edema, and drainage may be indicative of infection. The would should be well approximated. Option 2: Ecchymosis, redness, edema, and drainage may be indicative of infection. The would should be well approximated. Option 3: Ecchymosis, redness, edema, and drainage may be indicative of infection. The would should be well approximated. Option 4: Ecchymosis, redness, edema, and drainage may be indicative of infection. The would should be well approximated. Option 5: Ecchymosis, redness, edema, and drainage may be indicative of infection. The would should be well approximated.

Question 52. In addition to assessing bowel sounds, what other priority gastrointestinal assessment should be completed on a client following a cesarean section delivery? 1. Assessing for nausea 2. Last bowel movement before surgery 3. Assessing for flatulence 4. Tolerance of a full liquid d

ans 3 Option 1: Evaluating for nausea is important, but is not the main concern when also considering bowel sounds. Option 2: This past information does not impact the current assessment of the client. Option 3: Flatulence, or passing gas, along with active bowel sounds demonstrates peristalsis following abdominal surgery. Option 4: Following a c-section, most facilities allow for a return to full foods immediately after surgery.