The nurse is providing postpartum care for a client who gave birth by cesarean section several hours ago. The client had preeclampsia during the last 3 weeks of pregnancy. Which interventions are appropriate for this client within the first 48 hours after birth? Select all that apply.

Correct Answer: A

Rationale: In the postpartum care of a client who had preeclampsia and underwent a cesarean section, assessing deep tendon reflexes (Option A) is crucial within the first 48 hours after birth. This assessment is essential to monitor for signs of magnesium sulfate toxicity, a medication commonly used to prevent seizures in preeclampsia. Deep tendon reflexes can provide early indicators of magnesium sulfate toxicity, such as decreased or absent reflexes, helping to prevent potential complications. Assessment of intake and output (Option B) is not directly related to the client's condition of having had preeclampsia and a cesarean section. While it is important in general postpartum care, it is not a priority in this specific situation. Administering oxygen via nasal cannula (Option C) may not be necessary unless the client is showing signs of respiratory distress. There is no indication in the scenario provided that the client requires oxygen therapy at this time. Seizure precautions (Option D) are relevant due to the client's history of preeclampsia, which predisposes her to seizures. However, the most immediate concern within the first 48 hours after birth would be monitoring for magnesium sulfate toxicity through the assessment of deep tendon reflexes. Educationally, understanding the rationale behind each intervention helps nurses prioritize care based on the client's specific needs and condition. By comprehending the reasoning behind selecting the appropriate interventions, nurses can deliver safe and effective postpartum care to clients with complex medical histories like preeclampsia.

Correct Answer: D

Rationale: The client is being instructed in leg exercises and the pneumatic compression device to decrease the risk of developing deep vein thrombosis (DVT) postoperatively. DVT is a serious complication that can occur due to decreased mobility, venous stasis, and hypercoagulability associated with surgery. Leg exercises help promote circulation and prevent blood stasis in the veins, while pneumatic compression devices can also assist in improving blood flow and preventing the formation of blood clots in the deep veins of the legs. By reducing the risk of DVT, the client can avoid potential complications such as pulmonary embolism, which can be life-threatening.

Correct Answer: B

Rationale: In pediatric advanced life support (PALS) guidelines, the first step in CPR for a child in shock is to begin chest compressions, not ventilations. This is because the priority is to maintain blood flow to vital organs, especially in cases where the child's heart is not effectively pumping due to shock. By performing chest compressions immediately, the nurse can help circulate oxygenated blood throughout the child's body, increasing the chances of survival. Once chest compressions are initiated, ventilations can be added to support oxygenation and ventilation. Obtaining a defibrillator and establishing vascular access are important steps in advanced resuscitation but are not the initial actions in this scenario of a child in shock needing CPR.

Correct Answer: B

Rationale: Thyroid-stimulating hormone (TSH) is the test used to determine a patient's thyroid function. TSH is produced by the pituitary gland and stimulates the thyroid gland to produce thyroid hormones such as T3 (triiodothyronine) and T4 (thyroxine). Abnormal levels of TSH can indicate hypo- or hyperthyroidism, providing valuable information about the thyroid function of the patient. Therefore, when assessing thyroid function, TSH is the key laboratory test to review.

Correct Answer: A

Rationale: Before assessing the renal system, it is important for the patient to empty their bladder. This will allow for a more accurate assessment of the renal system, as a full bladder can interfere with the examination and may provide misleading results. Additionally, it helps the nurse to isolate any issues related to the renal system more effectively.