Pregnancy-high risk NCO
A client with mild preeclampsia is admitted to the high-risk prenatal unit because of a progressive increase in her blood pressure. The nurse reviews the primary healthcare provider's prescriptions. Which prescriptions does the nurse expect to receive for this client? Select all that apply. 1. Daily weight 2. Side-lying bed rest 3. 2 g/day sodium diet 4. Deep tendon reflexes 5. Glucose tolerance test
1. daily weight 2. side lying bed rest 4. deep tendon reflexes Rationale: Rapid weight gain is a sign of increasing edema. One liter of fluid is equal to 2.2 lb. Maintaining bed rest promotes fluid shift from the interstitial spaces to the intravascular space, which enhances blood flow to the kidneys and uterus; the side-lying position promotes placental perfusion. A 2 g/day sodium diet will deplete the circulating blood volume, limiting blood flow to the placenta. A moderate sodium intake (6 g or less) is permitted as long as the client is alert and has no nausea or indication of an impending seizure. Deep tendon reflexes should be monitored. Reflexes of +2 are indicative of mild preeclampsia; +4 indicates severe preeclampsia. There are no data indicating that a glucose tolerance test is needed.
The nurse is caring for a client whose fetus is in a breech presentation. The membranes rupture and meconium appears in the vaginal introitus. What does the nurse recognize this to indicate? 1. A potential for cord prolapse 2. Evidence of fetal heart abnormalities 3. A common occurrence in breech presentations 4. A condition requiring immediate notification of the primary healthcare provider
3. a common occurrence in breech presentations Rationale: Sudden rupture of membranes followed by the appearance of meconium occurs in breech presentation when pressure on the fetal abdomen from the contractions forces meconium from the bowel. Cord prolapse is not an absolute; however, it may occur if the presenting part does not fill the pelvic cavity. Fetal heart abnormalities are identified by means of auscultation or continuous electronic fetal monitoring, not by the presence of meconium. Immediate notification of the primary healthcare provider is unnecessary.
The nurse should be concerned about a client's mother-infant bonding if the client is reluctant to do what on the first postpartum day? 1. Undress the newborn 2. Breast-feed her newborn 3. Look at her newborn's face 4. Attend classes for newborn care
3. look at her newborn's face Rationale: Looking at the face or seeking eye-to-eye contact with the infant is an early sign of the initiation of bonding with the infant. The mother may feel inept or worry about upsetting the nurse by undressing her infant; new mothers need encouragement to undress their infants. Refusing to breast-feed her newborn may indicate that the mother is worried that she does not have enough milk, a common concern. The client may have attended prenatal classes, may be otherwise occupied, may not be feeling well enough to attend the class, or may feel that she has enough experience to care for her infant without attending a class for newborn care.
A grand multipara at 34 weeks' gestation is brought to the emergency department because of vaginal bleeding. The nurse suspects that the client has a placenta previa. Which characteristic typical of placenta previa supports the nurse's conclusion? 1. Painful vaginal bleeding in the first trimester 2. Painful vaginal bleeding in the third trimester 3. Painless vaginal bleeding in the first trimester 4. Painless vaginal bleeding in the third trimester
4. painless vaginal bleeding in the third trimester Rationale: As the lower uterine segment stretches and thins, painless tearing and bleeding occur at the low implantation site. First-trimester bleeding, painful or painless, is associated with spontaneous abortion or inadequate implantation, not placenta previa. Painful vaginal bleeding in the third trimester is usually associated with abruptio placentae rather than placenta previa.
A client at 36 weeks' gestation is admitted to the high-risk unit because she has gained 5 lb (2.3 kg) in the previous week and there is a pronounced increase in blood pressure. What is the initial intervention in the client's plan of care? 1. Preparing for an imminent cesarean birth 2. Providing a dark, quiet room with minimal stimuli 3. Initiating intravenous (IV) furosemide to promote diuresis 4. Administering calcium gluconate to lower the blood pressure
2. providing a dark, quiet room with minimal stimuli Rationale: Increasing cerebral edema may predispose the client to seizures; therefore stimuli of any kind should be minimized. It is too early to plan for a cesarean birth; other therapies will be tried first. The client will probably be given IV magnesium sulfate to prevent a seizure, not furosemide to promote diuresis. Magnesium sulfate will be used; calcium gluconate is its antidote.
A neighbor who is a nurse is called on to assist with an emergency home birth. What should the nurse do to help expel the placenta? 1. Put pressure on the fundus 2. Ask the mother to bear down 3. Have the mother breast-feed the newborn 4. Place gentle continuous tension on the cord
3. have the mother breast feed the newborn Rationale: Suckling will induce neural stimulation of the posterior pituitary gland, which in turn will release oxytocin and cause uterine contractions. Fundal pressure should not be used; it could cause uterine prolapse. Having the mother bear down could cause uterine prolapse. If the placenta is still attached to the uterine wall, placing gentle continuous tension on the cord could cause the cord to detach from the placenta or cause uterine prolapse.
When entering the room of a client in active labor to answer the call light, the nurse sees that she is ashen gray, dyspneic, and clutching her chest. What should the nurse do immediately after pressing the emergency light in the client's room? 1. Administer oxygen by facemask 2. Check for rupture of the membranes 3. Begin cardiopulmonary resuscitation (CPR) 4. Increase the rate of intravenous (IV) fluids
1. administer oxygen by face mask Rationale: The client is exhibiting signs and symptoms of an amniotic fluid embolism; increasing oxygen intake is essential. The client is experiencing an emergency situation; checking for rupture of membranes is irrelevant at this time. The client is breathing and conscious; CPR is not indicated, but it may become necessary if her condition worsens. It is not necessary to increase the IV fluid rate, although the current rate should be maintained.
A client who is 21 weeks pregnant experiences a fetal loss because of an incompetent cervix. Once the client's physical needs have been assessed and met, what is the best way for the nurse to address the client's psychologic needs? 1. Encouraging the client to see and hold the baby while still possible 2. Taking photos and giving them to the client if she refuses to see the baby 3. Sending the baby to the morgue as soon as possible and discouraging any contact 4. Telling the client that the baby is decaying and it is probably for the best if the is client unsure about seeing the baby
1. encouraging the client to see and hold the baby while still possible Rationale: Clients may respond differently to seeing a deceased baby. Some might want to see the baby right away; another might not want to let go; another might think it is improper; and yet another may need time beforehand. Explain to the client that seeing and holding the baby often confirms the death and provides time for the family to come together and grieve the loss. When and if the client is ready, wrap the infant in a blanket, hold it properly and treat it with respect, and pass the baby to the client. Photos should be taken of all fetal losses, held in a safe place, and cataloged, until the parents are ready to receive them. Make it known that they are available when ready. The baby needs to be maintained in a proper environment; the body may spend some time in a special place on the unit, providing time for decision-making; however, if too much time elapses before the mother makes a decision the body should be sent to the morgue. Depending on the facility, the nurse may ask that nothing be done with the body for at least 24 hours, in case the parents change their mind. Encourage the family to see and hold the infant if and when they are ready. Telling the client that her baby is decaying is insensitive and wrong.
A client is admitted to the birthing unit with uterine tenderness and minimal dark-red vaginal bleeding. She has a marginal abruptio placentae. The priority assessment includes fetal status, vital signs, skin color, and urine output. What additional assessment is essential? 1. Fundal height 2. Obstetric history 3. Time of the last meal 4. Family history of bleeding disorders
1. fundal height Rationale: It is vital that a baseline measurement be obtained, because increasing fundal height may be a sign of concealed hemorrhage. Taking an obstetric history, ascertaining the time of the last meal, and asking about a family history of bleeding disorders are all appropriate assessments; however, none are a priority at this critical time.
The nurse is teaching a prenatal class regarding the risks of smoking during pregnancy. What neonatal consequence of maternal smoking should the nurse include in the teaching? 1. Low birthweight 2. Facial abnormalities 3. Chronic lung problems 4. Hyperglycemic reactions
1. low birthweight Rationale: Smoking during pregnancy causes a decrease in placental perfusion, resulting in a newborn who is small for gestational age (SGA). Facial abnormalities and developmental restriction may occur if the woman ingests alcoholic drinks during pregnancy, resulting in fetal alcohol syndrome. Smoking during pregnancy and chronic lung problems in newborns are not related. Maternal smoking may result in a SGA neonate; these neonates may experience hypoglycemia, not hyperglycemia.
A nurse in the birthing suite has just admitted four clients. Which client should the nurse anticipate may require a cesarean birth? 1. Multipara with a shoulder presentation 2. Multipara with a documented station of "floating" 3. Primigravida with a fetus presenting in the occiput posterior position 4. Primigravida with a twin gestation with the lowermost twin in the vertex presentation
1. multipara with a shoulder presentation Rationale: A shoulder presentation in a multipara is indicative of a transverse lie, and this necessitates a cesarean birth. It is not uncommon for the fetus of a multipara to be high at the beginning of labor; early engagement occurs more often with a primigravida. With an occiput posterior position the labor may be longer, but usually the mother can give birth vaginally. If the first twin is in the vertex presentation, a vaginal birth will be attempted with a double setup; if possible, the birth of the second twin also will be attempted vaginally.
A client with a diagnosis of severe preeclampsia is admitted to the hospital from the emergency department. Which precaution should the nurse institute? 1. Padding the side rails on the bed 2. Placing the call button next to the client 3. Having oxygen and a facemask available 4. Assigning a nursing assistant to stay with the client
1. padding the side rails on the bed Rationale: Padded side rails help prevent injury during the clonic-tonic phase of a seizure. The client must be protected from injury if there is a seizure. Although some clients experience an aura before a seizure, there is not enough time to use a call button and wait for help. Oxygen is useless during a seizure when the client is not breathing or is thrashing about. Assigning a staff member to stay with the client in anticipation of a seizure is impractical and unproductive.
A primigravida is admitted to the emergency department with a sharp, shooting pain in the lower abdomen and vaginal spotting. A ruptured tubal pregnancy is diagnosed. During what week of gestation does this condition most commonly occur? 1. Sixth 2. Twelfth 3. Sixteenth 4. Eighteenth
1. sixth Rationale: In the sixth week the fallopian tube can no longer expand to accommodate the size of the growing embryo. A tubal pregnancy cannot advance to the twelfth, sixteenth, or eighteenth week, because the tube cannot expand to accommodate the growing fetus.
A client admitted to the high-risk unit with a threatened abortion anxiously asks the nurse, "Could this have happened because I had the flu?" How should the nurse respond? 1. "Tell me why you feel this way. Do you think that you did something to cause the bleeding?" 2. "We know that maternal infection sometimes results in spontaneous abortion. Perhaps the flu did cause it." 3. "I'm sure that there's nothing you could have done to cause this. You shouldn't worry about it." 4. "The primary healthcare provider will be here soon and will be better prepared to answer your questions. Why don't you wait until then?"
1. tell me why you feel this way. do you think that you did something to cause the bleeding? Rationale: Asking the client to talk about how she feels encourages the client to discuss her fears and anxieties. Stating that the flu may have caused the spontaneous abortion gives inaccurate information; this conclusion has not been documented, and this response adds to the guilt felt by the client. Telling the client that there is nothing she could have done to cause the problem does not focus on the client's feelings; it cuts off communication between the nurse and the client. Telling the client to wait until the primary healthcare provider arrives denies the client's feelings, abdicates the nurse's responsibility to the client, and cuts off communication. Also, it may increase anxiety because it implies that the nurse is not adequately prepared to care for the client.
A client at 24 weeks' gestation is admitted in early labor. What should the nurse take into consideration regarding this client's early gestation? 1. If contractions are regular, labor cannot be stopped effectively. 2. Birth at this gestational age usually results in a severely compromised neonate. 3. Attempts will be made to sustain the pregnancy for 2 or 3 more weeks to ensure neonatal survival. 4. Infants born at 30 to 34 weeks' gestation have a low morbidity rate because of advances in neonatal health care.
2. birth at this gestational age usually results in a severely compromised neonate Rationale: Morbidity and mortality rates among preterm neonates are highest between 24 and 26 weeks' gestation; complications include immature lung tissue, altered cardiac output, patent ductus arteriosus, intraventricular hemorrhage, necrotizing enterocolitis, and infection. Depending on the status of cervical effacement and dilation the decision may be made to try halting labor with the use of tocolytic medications and limited activity. If possible, the pregnancy should be maintained past 37 weeks' gestation. Neonates born at 34 weeks' gestation are still at high risk.
Which assessment finding in a pregnant client should prompt the nurse to notify the primary healthcare provider? 1. Slight dependent edema at 38 weeks' gestation 2. Fundal height at the umbilicus at 16 weeks' gestation 3. Fetal heart rate of 150 beats/min at 24 weeks' gestation 4. Maternal heart rate of 92 beats/min at 28 weeks' gestation
2. fetal heart rate of 150 beats/min at 24 weeks' gestation Rationale: Fundal height should be at the umbilicus at 20 weeks' gestation. This early fundal height increase indicates a hydatidiform mole, a multiple gestation, or a fetal congenital anomaly; at 16 weeks' gestation the fundus is below the umbilicus in a healthy, single pregnancy. Foot and ankle edema is common as pregnancy reaches term; the enlarged uterus presses on the femoral veins, impeding the flow of venous blood from the extremities. A fetal heart rate of 150 beats/min at 24 weeks' gestation and a maternal heart rate of 92 beats/min at 28 weeks' gestation are within the expected ranges during pregnancy.
After 8 postpartum hours the nurse determines that a client's fundus is 3 cm above the umbilicus and displaced to the right. Which statement is most significant in confirming the reason for the location of the uterus? 1. "I've been so thirsty the past few hours." 2. "I went to the bathroom, but I can't seem to urinate." 3. "I've changed my pad once since I got to my room." 4. "I've had a lot of contractions, especially while I was nursing."
2. i went to the bathroom, but i can't seem to urinate Rationale: Not being able to urinate, in conjunction with the other findings, suggests urine retention. Thirst is unrelated to the other findings; it is related to dehydration. Changing the pad once in 8 hours is an expected postpartum response. Contractions while breastfeeding are expected; oxytocin secretion, which is stimulated by infant suckling, causes the uterus to contract.
A client tells a nurse that she does not want an episiotomy and would rather tear naturally. What information should be offered to the client regarding each of these birthing methods? 1. Lacerations are more painful than an episiotomy. 2. Lacerations are easier to repair than an episiotomy. 3. An episiotomy causes less posterior trauma than lacerations. 4. An episiotomy is preferred over lacerations, according to evidence-based practice.
2. lacerations are easier to repair than an episiotomy Rationale: Lacerations require less suture time and cause less perineal trauma, which can have lifelong implications such as rectal-vaginal fistulas. Lacerations are less painful than an episiotomy and tend to heal more quickly. An episiotomy causes more posterior trauma than lacerations. Evidence indicates that a policy of routine episiotomy results in more perineal trauma, more suturing time, and more complications than lacerations.
The nurse is assessing several postpartum clients at the very beginning of her shift. Which problem does the nurse identify that might predispose a client to postpartum hemorrhage? 1. Preeclampsia 2. Multifetal pregnancy 3. Prolonged first-stage labor 4. Cephalopelvic disproportion
2. multifetal pregnancy Rationale: The presence of more than one fetus overdistends the uterus, which may result in uterine atony and thus postpartum hemorrhage. Preeclampsia and prolonged labor are not associated with postpartum hemorrhage. Cephalopelvic disproportion alone does not predispose a woman to postpartum hemorrhage.
A client with heart disease is admitted to the birthing suite. Which nursing intervention may help prevent the development of cardiac decompensation during her labor? 1. Positioning her on the side with her head on a pillow 2. Positioning her on the side with her shoulders elevated 3. Administering the prescribed intravenous (IV) infusion of isotonic saline 4. Administering the prescribed IV piggyback infusion of oxytocin
2. positioning her on the side with her shoulders elevated Rationale: The side-lying position, particularly the left, takes the weight off large blood vessels, increasing blood flow to the heart; elevating the shoulders relieves pressure on the diaphragm. The client's head is too low in this position if she is only positioned with her head on a pillow; it should be elevated above the shoulders. Sodium leads to increased fluid retention; it is contraindicated in a client with heart disease; if it is prescribed, the nurse should question the primary healthcare provider. Administering the prescribed IV piggyback infusion of oxytocin is contraindicated unless some uterine inertia occurs; if it is prescribed, the nurse should question the primary healthcare provider.
A client at 37 weeks' gestation is brought to the emergency department because of sudden abdominal pain. Abruptio placentae is suspected, and the client is transferred to the birthing unit. What should the nurse assess the client for? 1. Bright-red vaginal bleeding and multiple clots 2. Uterine tenderness and increased fetal activity 3. Cessation of contractions and decreased uterine size 4. Concealed hemorrhage and fetal heart rate accelerations
2. uterine tenderness and increased fetal activity Rationale: When the placenta initially separates, the fetus may become hyperactive as a response to acute hypoxia; the uterus is tender because of the accumulation of blood at the abrupted placental site. If bleeding occurs, it is dark red or port wine colored and usually does not clot. The uterus generally enlarges because of an accumulation of blood at the placental site. It is difficult to assess a client for concealed hemorrhage; the fetus must first be assessed for fetal heart tones to determine viability, not for increases or decreases in the heart rate.
A client with poorly controlled type 1 diabetes is now in her thirty-fourth week of pregnancy. The primary healthcare provider tells her that she should have an amniocentesis at 37 weeks to assess fetal lung maturity and that induction of labor will be initiated if the fetus's lungs are mature. The client asks the nurse why an early birth may be necessary. How should the nurse reply? 1. "You'll be protected from developing hypertension." 2. "Your glucose level will be hard to control as you reach term." 3. "The baby will be small enough for you to have a vaginal birth." 4. "The chance that your baby will have hypoglycemia will be reduced."
2. your glucose level will be hard to control as you reach term Rationale: Explaining that risk to the fetus increases as the pregnancy reaches term secondary to the mother's poorly controlled diabetes provides accurate information and answers the client's direct question. Labor is never induced for the sole purpose of preventing preeclampsia. This is not the reason for early induction; the longer the pregnancy is allowed to progress, the greater the risk for complications or a stillbirth; if the fetus becomes compromised, an emergency cesarean birth is usually required. Neonates can develop hypoglycemia shortly after birth related to many factors such as gestational diabetes and hypothermia, but this is not related to an early birth. The infant's size is anticipated to be larger than normal, not smaller.
In the second hour after a client gives birth, her uterus is found to be firm, above the level of the umbilicus, and to the right of midline. What is the appropriate nursing intervention at this time? 1. Checking for signs of retained placental fragments 2. Massaging the uterus to prevent hemorrhage 3. Assisting the client to the bathroom to empty her bladder 4. Telling the client that this is a sign of uterine stabilization
3. assisting the client to the bathroom to empty her bladder Rationale: A full bladder commonly elevates the uterus and displaces it to the right. Even though the uterus feels firm, it may relax enough to foster bleeding; therefore the bladder must be emptied to maintain uterine tone. Incomplete expulsion of parts of the placenta, umbilical cord, or fetal membranes during the third stage of labor limits uterine contraction and involution; a boggy uterus and bleeding will be evident. The uterus is firm and does not need massaging; however, if the bladder is not emptied, the uterus will not stay contracted, and massage will not make it firm. The positioning of this client's uterus is not a sign of uterine stabilization; the uterus cannot remain contracted in the presence of a full bladder.
A nurse in the prenatal clinic is caring for a client with heart disease who is in her second trimester. Which hemodynamic change of pregnancy is likely to affect the client at this time? 1. Decreased red blood cell count 2. Gradually increasing size of the uterus 3. Heart rate acceleration in the last half of pregnancy 4. Increase in cardiac output during the third trimester
3. heart rate acceleration in the last half of pregnancy Rationale: The heart rate increases by about 10 beats/min in the last half of pregnancy; this increase, plus the increase in total blood volume, can strain a damaged heart beyond the point at which it can efficiently compensate. The number of red blood cells does not decrease during pregnancy. The increased size of the uterus is related to the growth of the fetus, not to any hemodynamic change. Cardiac output begins to decrease by the thirty-fourth week of gestation.
A nurse is teaching a postpartum client the characteristics of lochia and any deviations that should be reported immediately. Which client statement indicates that the teaching was effective? 1. "If I pass any clots, I'll notify the clinic." 2. "I'll call the clinic if my lochia changes from red to pink." 3. "I'll notify the clinic if my lochia starts to smell bad." 4. "If my vaginal discharge continues for 3 weeks, I'll call the clinic."
3. ill notify the clinic if my lochia starts to smell bad Rationale: Lochia has a characteristic menstrual musky or fleshy smell. A foul-smelling discharge, along with fever and uterine tenderness, suggests an infection. Passing clots is a common occurrence. Lochia changing from red to pink is expected as lochia rubra progresses to lochia serosa. Although many women have a minimal discharge after 2 weeks, it is not uncommon for lochia alba to last 6 weeks.
At 12 weeks' gestation a client with a history of several spontaneous abortions says to the nurse, "Every day I wonder whether I'll be able to have this baby." How should the nurse respond? 1. "I can understand why you're worried; however, you'll have other chances in the future to get pregnant." 2. "You're getting the best of care. Please tell me about the problems with your previous pregnancies." 3. "It's understandable for you to be worried that you won't be able to carry this pregnancy to term. You've had a difficult time." 4. "Your pregnancy has lasted past the time when most early spontaneous abortions occur. I think you'll be able to continue the pregnancy."
3. it's understandable for you to be worried that you won't be able to carry this pregnancy to term. you've had a difficult time Rationale: Affirming the validity of the client's concerns acknowledges her fearful feelings. It also permits further communication. Assuring the client that she will have other chances to get pregnant in the future does not acknowledge the client's feelings; it also instills fear by implying that the current pregnancy may not go to term, even though there is no evidence to indicate this. Asking the client to talk about the problems with her prior pregnancies does not acknowledge her feelings of fear and changes the focus of the conversation. Telling the client that she should be able to continue the pregnancy is false assurance and does not address the client's feelings.
A client who has had a postpartum hemorrhage is to receive 1 unit of packed red blood cells (RBCs). The nurse manager observes a staff nurse administering the packed RBCs without wearing gloves. What does the nurse manager conclude? 1. The client does not have an infection. 2. The donor blood is free of bloodborne pathogens. 3. The nurse should have worn gloves for self-protection. 4. The nurse was skilled enough to prevent exposure to the blood.
3. the nurse should have worn gloves for self-protection Rationale: The Centers for Disease Control and Prevention (CDC) recommends that gloves be worn when there is the potential for contact with blood or other body fluids. Even if the client does not have an infection, gloves are always worn when exposure to blood or other body fluids is a possibility. All blood is considered potentially infectious. Nurses are required to take precautions that limit exposure; gloves must be worn.
A client at 35 weeks' gestation who has had no prenatal care arrives in labor and delivery and is found to be 20% effaced and 2 cm dilated. Her membranes are intact and contractions are 3 minutes apart. The nurse notices some ruptured blisterlike vesicles in the genital area. What should the nurse's next action be? 1. Educating the client on what to expect during labor 2. Discussing pain management options available during labor 3. Discussing the possibility of using oxytocin to move labor along 4. Contacting the primary healthcare provider regarding the need for a cesarean birth
4. contacting the primary healthcare provider regarding the need for a cesarean birth Rationale: Transmission of genital herpes simplex virus (HSV-2) to the newborn can occur during vaginal delivery when active lesions are present. Blindness, brain damage, or death could result if early measures are not taken. The priority is informing the primary healthcare provider of the presence of active genital herpes lesions so preparations for a cesarean birth may be made. The nurse would not want to enhance contractions; instead the nurse will begin preparations for a cesarean birth as soon as possible.
A client at term is admitted in active labor. She has tested positive for human immunodeficiency virus (HIV). Which intervention in the standard prescriptions should the nurse question? 1. Sonogram 2. Nonstress test 3. Sterile vaginal examination 4. Internal fetal scalp electrode
4. internal fetal scalp electrode Rationale: The electrode used for internal fetal monitoring pierces the fetal scalp; fetal exposure to maternal blood increases the risk of the fetus contracting HIV. Sonograms and nonstress tests are noninvasive tests that pose no risk to the fetus. Sterile vaginal examination is necessary to determine progression of labor; although invasive, it poses no risk to the fetus if standard precautions are used.
A pregnant client with severe abdominal pain and heavy bleeding is being prepared for a cesarean birth. What is the priority medical intervention? 1. Teaching coughing and deep-breathing techniques 2. Sterilizing the surgical site and administering an enema 3. Providing a sterile gown and inserting an indwelling catheter 4. Obtaining informed consent and assessing the client for drug allergies
4. obtaining informed consent and assessing the client for drug allergies Rationale: In an emergency surgical situation when invasive techniques are necessary, it is important to have a signed consent on file as well as a history of the client's known allergies. Teaching coughing and deep-breathing techniques is not a priority in an emergency such as this. In an emergency, sterilization of the surgical site is performed in the operating room; an enema usually is not given before a cesarean, especially to a client who is bleeding, because it may stimulate contractions and worsen the hemorrhage.