A client who is post-cesarean section for severe preeclampsia is receiving magnesium sulfate via IV pump and morphine sulfate via patient-controlled anesthesia (PCA) pump. The nurse enters the room on rounds and notes that the client is not breathing. Which of the following actions should the nurse perform first?

Correct Answer: A

Rationale: The correct answer is to give two breaths first (Option A) in the scenario described. In this situation, the client is not breathing, which indicates a critical respiratory issue that needs immediate intervention. Providing breaths is essential to support oxygenation and prevent hypoxia, which can lead to serious complications like brain damage or cardiac arrest. Discontinuing medications (Option B) should not be the first action because the priority is to address the client's breathing. While identifying and addressing potential medication-related causes is important, it should come after ensuring the client's airway and breathing are restored. Calling a code (Option C) may be necessary if the client's condition deteriorates further or if additional support is needed. However, initiating immediate rescue measures should take precedence over calling a code. Checking the carotid pulse (Option D) is not the most appropriate first action in this situation. While assessing the pulse is important to determine the client's overall condition, ensuring airway patency and ventilation is the immediate priority in a non-breathing client. Educationally, this scenario emphasizes the importance of prioritizing interventions in emergency situations. Nurses must be able to quickly assess and intervene in critical conditions to ensure the safety and well-being of their patients. Training in basic life support and emergency response protocols is crucial for all healthcare providers to effectively manage such situations.

Correct Answer: A

Rationale: The correct answer is A) Postpartum clients are at high risk for thrombus formation. In the postpartum period, especially after a cesarean section, women are at an increased risk for thrombus formation due to hormonal changes, immobility, and vascular damage during delivery. Intermittent positive pressure boots help prevent blood clots by promoting circulation in the lower extremities through intermittent compression. Option B) Post-cesarean clients are at high risk for fluid volume deficit is incorrect because although fluid volume deficit can occur post-cesarean due to blood loss during surgery, it is not the primary concern addressed by intermittent positive pressure boots. Option C) Postpartum clients are at high risk for varicose vein development is incorrect as varicose veins are not typically a primary concern immediately postpartum, and the use of intermittent positive pressure boots does not directly prevent varicose veins. Option D) Post-cesarean clients are at high risk for poor milk ejection reflex is incorrect as milk ejection reflex is related to breastfeeding, not to the need for intermittent positive pressure boots post-cesarean. Educationally, understanding the rationale for using specific interventions postpartum is crucial for providing safe and effective care to women during this vulnerable period. Recognizing the risks and implementing appropriate interventions, like intermittent positive pressure boots, can significantly impact postpartum outcomes and prevent complications such as thrombus formation.

Correct Answer: C

Rationale: In the immediate postpartum period following a low forceps delivery, the nurse should assess the woman for heavy lochia. Lochia is the vaginal discharge after childbirth, consisting of blood, mucus, and uterine tissue. In the case of a low forceps delivery, there is an increased risk of trauma to the birth canal and uterus, leading to heavier bleeding. Monitoring the amount, color, and odor of lochia is crucial to assess for postpartum hemorrhage, a significant concern after instrumental deliveries. The other options are incorrect for several reasons: A) Infection: While infection is a concern in the postpartum period, it is not specifically associated with a low forceps delivery unless there are signs or symptoms present. B) Bloody urine: Hematuria is not a typical finding related to a low forceps delivery. It may indicate genitourinary issues but is not a direct result of this type of delivery. D) Rectal abrasions: This is not a common complication of a low forceps delivery. While perineal trauma is possible, rectal abrasions are not a primary concern in this scenario. Educationally, understanding the potential complications and assessments required after different types of deliveries is essential for nurses caring for postpartum women. Recognizing the specific risks associated with instrumental deliveries like low forceps can help nurses provide targeted and effective care to promote optimal recovery and prevent complications.

Correct Answer: B

Rationale: In this scenario, the nurse should question the order for magnesium sulfate (option B) for the postoperative cesarean client with severe preeclampsia. Magnesium sulfate is commonly used in the management of severe preeclampsia during labor and delivery to prevent seizures (eclampsia). However, once the patient has transitioned to the postpartum unit, magnesium sulfate is typically discontinued unless there are specific ongoing indications. Option A, Methergine, is a medication used to prevent or control postpartum hemorrhage by causing uterine contractions. This medication is commonly ordered post-cesarean to help the uterus contract and prevent excessive bleeding. Option C, Advil (ibuprofen), is a nonsteroidal anti-inflammatory drug that is often prescribed postoperatively for pain relief and inflammation control, which is appropriate for a postoperative patient. Option D, Morphine sulfate, is a potent opioid analgesic that may be ordered for pain management postoperatively, especially after a cesarean delivery. Educationally, it's crucial for nurses to understand the rationale behind medication orders and to be vigilant in assessing the appropriateness of each medication for the specific clinical situation of the patient. In this case, recognizing the transition from labor and delivery to the postpartum unit and understanding the indications for each medication is essential for safe and effective patient care.

Correct Answer: B

Rationale: In this emotionally charged scenario, the most appropriate nursing action is option B: Sit with the family and quietly communicate sorrow at their loss. This response demonstrates empathy, compassion, and support during a time of deep emotional distress. By sitting with the family and expressing sorrow, the nurse validates their feelings and offers a comforting presence. Option A is incorrect because telling the father his behavior is inappropriate could escalate the situation further and is not the most therapeutic response in this context. Option C is wrong as it lacks empathy and fails to acknowledge that the 5-year-old's behavior is likely a manifestation of her distress and confusion. Option D is also inappropriate as it suggests avoiding the child's presence rather than addressing the family as a unit in need of support. From an educational standpoint, this scenario highlights the importance of therapeutic communication and empathy in nursing practice, especially in sensitive and challenging situations like perinatal loss. Nurses must prioritize emotional support, active listening, and non-judgmental presence to help families navigate through grief and loss effectively.