Davis Advantage Ch 11

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?

"Infants are less likely to need neonatal intensive care unit (NICU) care when placed skin-to-skin with the mother."

Following a cesarean section (C-section) a few hours ago, the partner of a client comes out to the nurses' station to report the client is experiencing severe pruritus. 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 the room to assess the concern?

"Itchiness, also known as pruritis, is a common reaction to morphine and is not considered an allergy."

While the nurse is preparing a client for an emergency cesarean section (C-section), the family voices concern that the client is extremely nervous about the procedure. How does the nurse respond to the client?

"Tell me about how you are feeling right now."

A provider has determined a client needs a cesarean section (C-section) for cephalopelvic disproportion. The client asks the nurse to explain what cephalopelvic disproportion means. What is the best response by the nurse?

"The baby is too large for you pelvis."

While presenting an educational session on childbirth, the nurse was asked to discuss risk factors for a cesarean section (C-section). What should the nurse include in her response?

- Advanced maternal age - Breech position

Nursing responsibilities during a cesarean section include which of the following?

- Calling time-outs - Placing identification bands on the infant and parents - Placing the infant skin to skin

A nurse is preparing to assist a new mother with breastfeeding following a cesarean section (C-section) delivery. Which positions will the nurse recommend to maximize patient comfort while breastfeeding?

- Side-lying position - Football hold

A nurse is caring for a client following a cesarean section (C-section) 4 hours ago that occurred due to arrest of labor. Initially, the client was admitted to the hospital 2 days ago after experiencing spontaneous rupture of membranes. Which medication order does the nurse anticipate for this client?

Ampicillin

While assessing a postoperative cesarean section (C-section) client, the nurse notes a temperature of 102.1°F (38.9°C). Before calling the provider, what other assessment should the nurse complete to include when reporting the concern?

Assess the C-section incision.

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 (C-section) deliveries. Which couplet will need to be seen first?

Couplet #2: The infant has been breastfeeding successfully and the mother has required fundal massage for the fundus to become firm.

This or That? Identify which situation or complication would result in a scheduled, nonurgent, or emergent cesarean section. A prolapsed cord occurring during artificial rupture of membranes

Emergent Rationale: A prolapsed cord is a medical emergency and needs to be delivered as quickly as possible to prevent fetal injury, hypoxemia, and death.

This or That? Identify which situation or complication would result in a scheduled, nonurgent, or emergent cesarean section. Uterine rupture due to a placental accreta

Emergent Rationale: A uterine rupture is always a medical emergency.

This or That? Identify which situation or complication would result in a scheduled, nonurgent, or emergent cesarean section. Maternal disseminated intravascular coagulation (DIC)

Emergent Rationale: DIC is a medical emergency. A patient who develops DIC will need to be delivered immediately to prevent maternal and/or fetal death or significant complications.

This or That? Identify which situation or complication would result in a scheduled, nonurgent, or emergent cesarean section. Maternal tachycardia and a category III tracing

Emergent Rationale: Maternal tachycardia accompanied by a category III tracing on the fetal heart monitoring (FHM) is indicative of a hemorrhage and would need to be delivered as quickly as possible.

Sally is a 38-year-old G3P1011 at 33 weeks 4 days admitted to antepartum for a placenta previa. She's begun having painless, heavy bleeding, has a category III strip, and her vital signs are 100/51 mm Hg, pulse 108, respirations 20, oxygen saturation 94%, temperature 99.8°F. What type of cesarean section will she receive?

Emergent, immediately

This or That? Identify which situation or complication would result in a scheduled, nonurgent, or emergent cesarean section. A patient in labor for 32 hours whose three most recent sterile vaginal exams (SVEs) over the last 12 hours have been 7/90/0 station

Nonurgent Rationale: This would indicate a failure to progress and an indication the infant may have a malpresentation or complication with the cervix preventing it from dilating. This patient would need to be delivered soon, but it would not be emergent.

A term, multiparous, laboring client has just had a SROM, and the nurse has performed an SVE. Based on the assessment findings, what does the nurse anticipate the provider's next course of action to be?

Perform an emergent C-section

Following a cesarean section (C-section), the nurse caring for the client notes the following assessment data: temperature 99.1°F, heart rate 136, respirations 20, blood pressure 82/48 mm Hg. Her skin is pale and clammy to the touch. The nurse reports concern of what postpartum complication to the provider?

Postpartum hemorrhage

An example of a complication that would require an emergent cesarean section is __________.

Prolapsed cord

Cesarean sections can often be avoided by ___________________.

Reserving labor induction for medical interventions only.

This or That? Identify which situation or complication would result in a scheduled, nonurgent, or emergent cesarean section. A G5P2113 patient with a history of prior cesarean deliveries

Scheduled Rationale: A history of prior cesarean deliveries is one of the primary reasons for a repeated cesarean section, though trail of labor after Cesarean (TOLAC) is an option depending on the number of cesarean sections the patient has had compared to vaginal births.

This or That? Identify which situation or complication would result in a scheduled, nonurgent, or emergent cesarean section. Placenta previa in an asymptomatic patient admitted to antepartum at 32 weeks' gestation

Scheduled Rationale: As long as the patient remains stable and under observation, she will be scheduled for a cesarean section to allow the fetus as much time in utero as possible. If the patient develops bleeding, this will become an urgent cesarean, as long as the infant maintains a category I strip. If the fetal heart tone becomes abnormal, it may turn into an emergent cesarean.

This or That? Identify which situation or complication would result in a scheduled, nonurgent, or emergent cesarean section. Multiple gestation with the presenting twin breech

Scheduled Rationale: Breech gestations are considered a malpresentation and are delivered via cesarean section due to possible risks and complications.

This or That? Identify which situation or complication would result in a scheduled, nonurgent, or emergent cesarean section. Cephalopelvic disproportion (CPD) identified in an ultrasound

Scheduled Rationale: Cephalopelvic disproportion can present in labor as the infant failing to descend into the pelvis. But if CPD is determined as a malpresentation prior to delivery by assessment and/or ultrasound that detects a small maternal pelvis or a large cranial diameter on the infant, the patient will be scheduled for a cesarean section.

This or That? Identify which situation or complication would result in a scheduled, nonurgent, or emergent cesarean section. A G2P1001 patient who had surgery last year to remove a mass on her uterine wall. She was surprised she was able to get pregnant due to the extent of the surgery.

Scheduled Rationale: Previous uterine surgery, or surgeries that went through the myometrium of the uterus, are an indication for a cesarean section.

The nurse is assessing a client 12 hours post-cesarean section (C-section) delivery of a healthy male infant weighing 9 pounds 3 ounces. The client's Foley catheter was removed 3 hours ago. Which subjective assessment data requires immediate intervention?

The client reports no voiding since the catheter was removed.

A client is pregnant with her second child following a cesarean section (C-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?

Vaginal birth

The obstetric nurse is preparing a client for an epidural. What is the priority nursing intervention before this procedure?

Administer Iv fluid bolus

Postoperative care of a stable mother and infant includes all of the following except ___________.

Placing the infant in the nursery to promote rest