The surgeon has removed the surgical cesarean section dressing from a post-op day 1 client. Which of the following actions by the nurse is appropriate?

Correct Answer: B

Rationale: In this scenario, option B, "Monitor the incision for drainage," is the most appropriate action for the nurse to take after the surgeon has removed the cesarean section dressing from a post-op day 1 client. This is the correct answer because monitoring the incision for drainage is essential in assessing for signs of infection, which is a common complication postpartum. Drainage from the incision site could indicate infection, and early detection is crucial for prompt intervention and prevention of further complications. Option A, "Irrigate the incision twice daily," is incorrect because irrigating the incision without proper assessment and orders from the healthcare provider can introduce pathogens and disrupt the healing process. Option C, "Apply steristrips to the incision line," is incorrect because applying steristrips is not within the nurse's scope of practice without specific orders from the healthcare provider. Steristrips are typically applied during the initial closure of the incision by the surgeon. Option D, "Palpate the incision and assess for pain," is incorrect because palpating the incision can introduce pathogens and increase the risk of infection. Assessing for pain is important, but monitoring for drainage is a more immediate concern in this situation. In an educational context, understanding proper postoperative wound care is crucial for nursing practice. Nurses need to know how to assess incisions for signs of complications, such as infection, and follow evidence-based guidelines to provide safe and effective care to postpartum clients. Monitoring for drainage is a fundamental aspect of wound care assessment and plays a vital role in early detection and management of complications.

Correct Answer: A

Rationale: In the context of postpartum complications, adequate rest is crucial for the mother's physical and mental well-being. Option A, "Plan to sleep or rest any time the infant sleeps," is the best choice because it aligns with the concept of maximizing rest opportunities during the newborn's sleep cycles. This approach allows the mother to recuperate, promote healing, and manage potential postpartum complications more effectively. Option B, "Do all housecleaning while the infant sleeps," is incorrect as it neglects the importance of rest for the mother, which is essential for her recovery and overall health. Engaging in housecleaning activities during the infant's sleep time can lead to exhaustion and may exacerbate postpartum complications. Option C, "Cook several meals at once and freeze for later use," although helpful in managing time and reducing stress, does not directly address the need for rest, which is the primary concern in the postpartum period. Option D, "Tell family and friends not to visit for the first month," is also incorrect as social support is crucial for the mother's well-being postpartum. However, setting boundaries and managing visitors' expectations to ensure that the mother has ample time to rest is essential. In an educational context, it is important to emphasize to new mothers the significance of prioritizing rest and self-care in the postpartum period. By understanding and implementing strategies like sleeping or resting when the infant sleeps, mothers can better manage postpartum complications and promote a smoother recovery process.

Correct Answer: C

Rationale: In postpartum care, uterine massage is a crucial intervention to prevent postpartum hemorrhage by promoting uterine contraction. Placing one hand above the symphysis pubis during uterine massage helps prevent the uterus from inverting by providing counter-pressure as the fundus contracts. This is essential to maintain uterine position and prevent potential complications such as uterine inversion, which can lead to severe bleeding and shock. Option A is incorrect because the primary goal of uterine massage is not to make the woman more comfortable but to ensure proper uterine contraction. Option B is incorrect as the location of the hand does not necessarily increase the effectiveness of the procedure; rather, it is about providing specific support to prevent uterine inversion. Option D is also incorrect as determining the firmness of the uterus can be achieved by palpating the fundus, not by the hand's placement above the symphysis pubis. Understanding the rationale behind proper uterine massage technique is crucial for nurses and healthcare providers caring for postpartum women. By knowing the correct hand placement and its purpose, they can effectively prevent complications and ensure optimal postpartum care for their patients.

Correct Answer: C

Rationale: In the postpartum period, constipation is a common issue due to factors like hormonal changes, decreased abdominal muscle tone, and fear of pain during bowel movements. Teaching the postpartum woman to drink at least 1600 mL of noncaffeinated fluids daily is crucial in preventing constipation. Adequate hydration softens stool, making it easier to pass and preventing constipation. Option A is incorrect because foods like milk, cheese, and yogurt can actually help prevent constipation due to their fiber content. Option B is not recommended as a routine practice because using laxatives can lead to dependency and disrupt natural bowel function. Option D is also incorrect as walking encourages bowel motility and can actually help prevent constipation in the postpartum period. Educationally, it is important to teach evidence-based strategies to promote postpartum health and prevent complications. By understanding the physiological changes that occur postpartum, nurses can provide targeted education to support women in their recovery and promote optimal well-being.