The nurse is developing a standard care plan for the post-cesarean client. Which of the following should the nurse plan to implement?

Correct Answer: B

Rationale: The correct answer is B) Teach sitz bath use on the second postoperative day. Post-cesarean clients experience hormonal changes that affect their physical and emotional well-being. Teaching sitz bath use promotes perineal healing, reduces the risk of infection, and provides comfort. It also encourages self-care and empowers the client in her recovery process. Option A is incorrect as maintaining the client in a left lateral recumbent position is not typically necessary post-cesarean section. Option C is incorrect because performing active range-of-motion exercises may not be suitable immediately post-cesarean due to pain and the need for rest and healing. Option D is incorrect because assessing central venous pressure is not a standard nursing intervention for a post-cesarean client. This procedure is typically reserved for specific medical conditions and not routine postoperative care. Educationally, understanding the rationale behind each option helps nurses develop critical thinking skills in providing individualized care based on the client's needs and condition. It also emphasizes the importance of evidence-based practice in postpartum care.

Correct Answer: C

Rationale: In a 3-week-multigravid postpartum client with postpartum depression, the nurse should expect to observe feelings of failure as a mother. This is the correct answer because postpartum depression often manifests as feelings of inadequacy, guilt, and worthlessness, leading the mother to believe she is not capable of being a good mother. Option A, feelings of infanticide, is incorrect as this is a severe symptom of postpartum psychosis, not postpartum depression. Option B, difficulty with breastfeeding latch, is a common challenge in the postpartum period but is not specifically associated with postpartum depression. Option D, concerns about sibling jealousy, may be a valid concern for some mothers but is not typically a significant behavior seen in postpartum depression. Educationally, understanding the behavioral manifestations of postpartum depression is crucial for healthcare providers to provide appropriate support and interventions for mothers experiencing this condition. By recognizing the signs and symptoms, healthcare professionals can offer timely and effective care to promote the well-being of both the mother and the newborn.

Correct Answer: C

Rationale: The correct answer is C: "The best way to keep your baby from getting sick is for you to keep breastfeeding him rather than switching him to formula." Explanation: Breastfeeding provides the baby with essential antibodies and nutrients that can help protect against illnesses. By continuing to breastfeed, the mother passes on her immune system's defense mechanisms to the baby, reducing the chances of the baby getting sick. Breast milk is a complete source of nutrition and immune protection for infants, making it the best option for their overall health, especially when the mother is sick. Option A is incorrect because while boiling water is important for formula preparation to prevent infections like diarrhea, it is not necessary in this scenario. Option B is incorrect because while pumping breast milk is essential for maintaining milk supply, it is not the best solution in this situation where breastfeeding is still the optimal choice. Option D is unnecessary and may cause unnecessary alarm as wearing a surgical mask is not typically recommended unless the mother is showing symptoms of a contagious illness like the flu. In an educational context, it is crucial to emphasize the importance of breastfeeding for both the baby's and the mother's health. Educating mothers about the benefits of breastfeeding, especially during times of illness, can help them make informed decisions that promote the well-being of their child. It is also essential to provide support and resources to help mothers continue breastfeeding successfully, even during challenging times.

Correct Answer: C

Rationale: In caring for a postoperative cesarean client who is obese and insulin-dependent, it is crucial for the nurse to carefully monitor for wound dehiscence. Rationale for the correct answer (Option C): Wound dehiscence is a serious complication in obese and diabetic patients due to impaired wound healing, increased risk of infection, and compromised tissue integrity. The combination of obesity and diabetes further exacerbates these risks, making wound dehiscence a significant concern that can lead to severe complications if not promptly detected and managed. Rationale for incorrect options: A) Failed lactogenesis: While important for postpartum care, failed lactogenesis is not typically directly related to obesity or diabetes in the immediate postoperative period following a cesarean section. B) Dysfunctional parenting: This is not a physiological complication related to the client's medical conditions or postoperative status. D) Projectile vomiting: While vomiting can be a concern postoperatively, projectile vomiting is not specifically associated with obesity or diabetes in this context. Educational context: Understanding the specific risks and complications associated with obesity and diabetes in the postpartum period is essential for nurses caring for these patients. Monitoring for wound dehiscence, in particular, is critical due to the increased vulnerability of these patients to wound-related complications. Early recognition and intervention can help prevent further issues and promote optimal healing outcomes for the client.

Correct Answer: C

Rationale: In the immediate postpartum period, hormonal changes can affect a woman's vital signs. The correct interpretation of the findings in this case is option C: "Respirations are too low, a sign of medication toxicity." Postoperative cesarean clients often receive pain medications, which can depress the respiratory drive and lead to hypoventilation. This is supported by the normal temperature, pulse, and blood pressure readings in this scenario. Option A (Temperature is elevated, a sign of infection) is incorrect because the temperature of 100.0°F is within normal limits for the postpartum period and can be attributed to the normal inflammatory response after surgery. Option B (Pulse is too low, a sign of vagal pathology) is incorrect as a pulse of 68 beats per minute is within the expected range for a postoperative client and does not indicate vagal pathology. Option D (Blood pressure is elevated, a sign of preeclampsia) is incorrect as the blood pressure reading of 130/80 is also within normal limits for the postpartum period and does not suggest preeclampsia. Educationally, it is vital for nurses to understand the expected physiological changes in the postpartum period and how to differentiate normal variations from potential complications. Monitoring vital signs and recognizing signs of medication toxicity are crucial skills for postoperative care to ensure the safety and well-being of the mother.