Author Question: A nurse is caring for a woman after a cesarean birth. Prior to ambulating her for the first time, ... (Read 136 times)

cookcarl · **on:** Jun 28, 2018

A nurse is caring for a woman after a cesarean birth. Prior to ambulating her for the first time, which action by the nurse takes priority?

A.
Assess sensation in the lower extremities.
B.
Discontinue the patient's intravenous line.
C.
Encourage the patient to cough and deep breathe.
D.
Have the patient sit on the edge of the bed.

Question 2

A woman complains of perineal pain. The nurse assesses swelling, but sees no other abnormalities. The woman does not wish pharmacological treatment. What suggestion by the nurse is most appropriate?

A.
Applying a covered ice pack to the perineum every 2 to 4 hours for 20 minutes
B.
Placing cool cabbage leaves on the woman's peri-pad
C.
Sitting on a donut-type pillow when out of bed
D.
Immersing in a sitz bath with a water temperature of 120 F (48.9 C)

TDubDCFL · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: A
After a cesarean birth with spinal or epidural anesthesia, the nurse must assess sensation in the woman's legs. She will not be allowed out of bed until sensation returns. Discontinuing the IV line may or may not be appropriate. Coughing and deep breathing are always important for a postoperative patient, but this action is not related to ambulating for the first time. Sitting on the edge of the bed prior to getting up would only be done if the woman had full sensation in her legs.

Answer to Question 2

ANS: A
An ice pack, wrapped in cloth, can be applied to the perineum for 20 minutes every 2 to 4 hours for discomfort. Ice has vasoconstrictive and numbing effects. Cooled cabbage leaves can be placed against the woman's breasts to help with engorgement. Donut pillows are not recommended because they spread the buttocks and increase pain, especially if the woman has hemorrhoids. Sitz bath water should be no higher than 105 F (40.5 C).