Intermittent positive pressure boots have been ordered for a client who had an emergency cesarean section. Which of the following is the rationale for that order?

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: 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.

Correct Answer: A

Rationale: In this scenario, option A is the correct answer indicating poor mother-infant bonding. The mother's statement of being tired and requesting the baby to be fed in the nursery suggests a lack of interest in caring for the infant, which can be indicative of poor bonding. Option B demonstrates the mother acknowledging the baby's physical features, which shows some level of engagement and recognition of the baby. Option C indicates a positive act of naming the baby after a family member, which reflects a connection and thoughtfulness towards the infant. Option D highlights the mother's effort to breastfeed the baby, showing a willingness to provide care and nurture, although she seeks assistance with swaddling, which is common for new mothers. Educationally, this question highlights the importance of assessing mother-infant bonding in the postpartum period. It emphasizes the need for healthcare providers to be vigilant for signs of poor bonding, as it can impact the overall well-being of both the mother and the baby. Recognizing these signs early allows for timely interventions and support to strengthen the bond between the mother and infant.

Correct Answer: B

Rationale: The correct answer is B) INR (international normalized ratio) of 2.5. In the context of a client on Coumadin post-pulmonary embolism after a cesarean delivery, the INR value of 2.5 indicates that the medication is effective in achieving the desired anticoagulant effect. INR is used to monitor the effectiveness of warfarin therapy, with a target range typically between 2.0 to 3.0 for conditions like pulmonary embolism. Option A (PT of 12 sec) is within the normal range, but PT alone is not as specific or sensitive as the INR for monitoring warfarin therapy. Option C (Hematocrit 55%) and D (Hemoglobin 10 g/dL) are not directly related to monitoring the effectiveness of Coumadin therapy in this scenario. Educationally, understanding the significance of monitoring INR in patients on warfarin is crucial for healthcare professionals managing postpartum clients with thromboembolic complications. This knowledge ensures safe and effective anticoagulant therapy to prevent complications like recurrent thromboembolism. Regular monitoring and interpretation of INR values are essential to adjust the dosage of Coumadin for optimal therapeutic outcomes.