A nurse is providing discharge instructions to a postpartum person who had a cesarean birth. What is the most important instruction to include?

Correct Answer: B

Rationale: The correct answer is B: encourage deep breathing exercises. Deep breathing helps prevent complications like pneumonia after surgery, aids in lung expansion, and promotes overall respiratory health. Choice A is important but not the most crucial post-cesarean. Choice C promotes mobility but doesn't address immediate respiratory needs. Choice D is important but not the most vital in the early postpartum period.

Correct Answer: C

Rationale: The correct answer is C: perform gentle uterine massage. This intervention is appropriate as it helps to stimulate uterine contractions, which can reduce postpartum bleeding and pain. Uterine massage also helps to promote involution of the uterus, aiding in the recovery process. Administering IV fluids (A) may be necessary but does not directly address pain management. Administering narcotics (B) may provide pain relief but should be used judiciously due to potential side effects. Performing gentle fundal massage (D) is not recommended as it may cause discomfort and is not as effective in managing post-cesarean pain compared to uterine massage.

Correct Answer: A

Rationale: The correct answer is A: administer a preoperative medication. This is the most important action because it helps prepare the laboring person for the cesarean birth by ensuring they are adequately medicated for the procedure. Administering preoperative medication can help reduce anxiety, manage pain, and ensure the person is in a suitable condition for surgery. Summary of other choices: B: Assisting with positioning the person is important but not the most critical action before a cesarean birth. C: Performing a cesarean section is not a nursing responsibility and is done by the healthcare provider. D: Monitoring fetal heart tones is important but not the most crucial action for preparing the laboring person for a cesarean birth.

Correct Answer: C

Rationale: The primary goal of using forceps in delivery is to help expel the placenta. Forceps are not typically used to assist with fetal descent, provide immediate relief of shoulder dystocia, or avoid unnecessary surgical interventions. Forceps are specifically designed to aid in the safe and efficient removal of the placenta after the baby has been delivered. This minimizes the risk of postpartum hemorrhage and other complications.

Correct Answer: B

Rationale: The correct answer is B: prepare the person for a cesarean section. In the scenario of vacuum extraction, if there are complications or the procedure is unsuccessful, the person may need to undergo an emergency cesarean section. By preparing the person for this possibility, the nurse ensures timely intervention if needed, prioritizing the safety of both the person and the baby. Monitoring fetal heart rate continuously (A) is important but not the most crucial action in this case. Monitoring for signs of uterine rupture (C) is not directly related to vacuum extraction. Assisting with positioning (D) is important but not as critical as preparing for a potential cesarean section.