CH 24 CS PT Scenario

Patient Scenario, Chapter 24, Nursing Care of a Family During a
Surgical Intervention for Birth
A WOMAN HAVING A CESAREAN BIRTH

Linda Okparo a 25-year-old, G2P1, 41-week pregnant woman is scheduled for an
elective cesarean birth in 2 days.
CHIEF CONCERN:
She has come for her preoperative blood work; she appears tense and nervous.
HISTORY OF CHIEF CONCERN:

The client was told by her obstetrician 2 days ago she will need to have a cesarean
birth because, due to pelvic injury and contracture from an automobile accident a
year ago, her baby will be too large for her pelvic measurements to be born
vaginally. She is concerned because her last child was a home birth in her native
country of Ghana 5 years ago; she has never been hospitalized nor had surgery in
the past.
FAMILY PROFILE:
The client lives with her two sisters in a two-bedroom apartment on the third floor of
a six-story walk-up. She is currently unemployed. Her 5-year-old daughter lives in
Ghana with her grandmother.
HISTORY OF PAST ILLNESSES:

She had an appendectomy at age 14 years. Her black mole removed from left
shoulder at age 4 years ago; no malignancy found on biopsy. She had herpes
infection 2 years ago. She has no lesions at present.
HISTORY OF FAMILY ILLNESSES:

Her mother has adult onset diabetes. A sister has hypertension.
GYNECOLOGIC HISTORY:
Menarche was at age 11 years; cycle duration: 21 days; duration of menstrual flow:
7 days; moderate dysmenorrhea.
OBSTETRIC HISTORY:
She had previous pregnancy: a female child at term 5 years ago, 8 lb at birth. Her
present pregnancy, she had prenatal care at community clinic; she had no
complications or concerns until this week.
DAY HISTORY:
This study source was downloaded by 100000816355325 from CourseHero.com on 03-11-2024 10:40:29 GMT -05:00
https://www.coursehero.com/file/84004741/Ch-24-CS-Pt-scenario-docx/
Nutrition: 24-hour nutrition recall reveals adequate pregnancy diet; prenatal vitamin
taken daily
Sleep: Sleeps 6 hours a night; no difficulty
Recreation: Walks for 30 minutes daily in community park
REVIEW OF SYSTEMS:
Genitourinary: Frequent yeast infections she treats herself with over-the-counter
fungicide suppositories
Extremities: Slight swelling of ankles since 30th week of pregnancy
PHYSICAL EXAMINATION:
General appearance: African American, obese-appearing, pregnant female with
slight swelling of ankles; height: 5 ft 6 in.; weight: 210 lb; blood pressure:
127/77 mmHg
Level of consciousness: Alert and oriented, although she appears tense and agitated
HEENT: Slight swelling of gum line noted
Chest: Heart rate: 90 beats/min; no murmurs; respiratory rate: 22 breaths/min;
lungs clear bilaterally
Abdomen: Fundal height: 45 cm; linea nigra present on abdomen; fetus assessed to
be in left anterior position by Leopold’s maneuvers; no uterine contractions
present; FHR: 140 to 150 beats/min; estimated fetal weight: 4.2 kg (9.2 lb)
Pelvic examination: Deferred
Extremities: Full range of motion
LABORATORY REPORTS:
Hemoglobin: 11.2 g/dl
Hematocrit: 33%
Urinalysis: Negative for protein and glucose; specific gravity: 1.030
STUDY QUESTIONS:
1. Based on Linda’s health history, what is the most appropriate nursing diagnosis for her at this time?
a. Spiritual distress related to changing situation
b. Knowledge deficit about cesarean birth
c. Risk of maternal injury related to surgery
d. Anxiety related to impending surgery
2. Based on Linda’s reaction to the news that she needs to have a cesarean birth, what would be your
most important nursing action?
a. Explain more information about the procedure.
b. Provide emotional support because she was so surprised.
c. Involve her partner in the surgical experience.
d. Describe the way that she will be prepared for surgery.
3. How would you describe a cesarean birth procedure to Linda?
a. “It is an incision made high on your abdomen over the uterus.”
b. “It is an incision through the lower abdomen into the wall of your uterus.”
c. “Instruments that look like tongs will be used to remove the baby.”
d. “A soft or flexible vacuum cup is used to remove the baby’s head through your abdomen.”
4. Although Linda is, overall, a healthy young adult, which of the following from her health history
makes her a surgical risk?
a. She has a history of recurrent yeast infections.
b. She has no past experience with surgery.
c. She is 25 years old.
d. She is assessed as being obese.
5. Thirty minutes before transporting Linda to the operating room on the day of her surgery, you
administer sodium citrate (Bicitra) to Linda. You should describe what rationale for giving her this
medication?
a. “This is an antibiotic to prevent infection.”
b. “This is a sedative which will help you relax.”
c. “As you lie flat, this medication should prevent dizziness.”
d. “This medicine helps to neutralize your stomach acid during surgery.”
6. Linda asks you why she has to remove her nail polish prior to her cesarean birth. What rationale
should you cite?
a. Clear nails are better for assessing oxygenation and capillary refill.
b. Clear nails present less of an infection risk.
c. Nail polish is a difficult to disinfect prior to surgery.
d. Fingernails without polish make it easier to assess hydration status.
7. During cesarean birth, women have a pillow roll placed under their left hip. You should explain that
this intervention is aimed toward what goal?
a. Decreasing surgery blood loss
b. Supporting the surgeon’s hands
c. Increasing maternal comfort
d. Preventing supine hypotension
8. After her cesarean birth, Linda will be transferred from the operating room to the recovery room.
What would be your most important action?
a. Use a slide board for safe transfer to a recovery bed.
b. Urge Linda to sit up and slide over onto a stretcher.
c. Help Linda into a wheelchair for safe transportation.
d. Help Linda walk with assistance to the recovery room.
9. Because Linda’s baby was born by a cesarean birth, what neonatal assessment should you first
prioritize?
a. Assessment for signs of jaundice
b. Assessment for signs of anemia
c. Assessment for respiratory distress
d. Assessment for shoulder injury
10. Four hours after surgery, you are asked to assess if Linda’s bowel function has returned. How
should you best perform this assessment?
a. By asking her if she feels bowel function
b. By listening for abdominal bowel sounds
c. By assessing if she is having incisional pain
d. By asking if she has had a bowel movement yet
11. Linda had her urinary catheter removed 8 hours after surgery. You would document her bladder as
being distended if you obtained what assessment finding?
a. Her bladder sounds dull to percussion.
b. Her bowel sounds are indistinct and soft.
c. Her bladder sounds resonant on percussion.
d. Her bladder in nonpalpable.
12. You want to assess if Linda’s uterus is contracted following surgery. To do this best, you will inform
her that you will perform what action?
a. Observe her abdominal contour for bulging and tension.
b. Palpate her uterus to ascertain its height and consistency.
c. Inspect her incision to be certain no bleeding is present.
d. Percuss her uterus for fullness and intensity of sound.
13. Linda’s primary care provider asks you to “check Linda’s legs.” The most important reason to do
this assessment postcesarean birth would be to assess for what health problem?
a. Varicose veins
b. Decreased ankle range of motion
c. Thrombophlebitis
d. Decreased capillary refill
14. You have been careful to refer to Linda’s procedure as a cesarean birth rather than a cesarean
section. What is the rationale for referring to it as a cesarean birth?
a. Cesarean birth is a recognized NANDA diagnosis.
b. It accentuates the main result here is birth, not surgery.
c. The term convinces women they are not having surgery.
d. It is necessary to use this term for hospital billing purposes.
15. Linda tells you she plans to travel to Ghana in 2 weeks with the baby. What would be your best
response?
a. “Make sure you get the baby immunized before you leave.”
b. “Be sure the baby has a passport because you will need that.”
c. “Please discuss your plans with your primary care provider.”
d. “You will need to have your stitches taken out before you go.”
16. Linda received an analgesic 2 hours ago and you are now encouraging her to ambulate. She tells
you she is stiff and tired and does not want to move. What would be your best action?
a. Let her rest; all surgical procedures are a major stress to body systems.
b. Offer her more or different analgesia to make her feel better.
c. Communicate that early ambulation is needed to prevent complications.
d. Document her refusal and notify her primary care provider.
17. While still in the operating room, how could you help promote bonding between Linda and her
newly born baby who is stable?
a. Let her view the baby through the dome of the incubator.
b. Promptly wrap the baby and bring him or her to her so she can touch the baby.
c. Hold up the baby and show the baby to her over the drape.
d. Let her cut the baby’s cord.
18. Linda is in the recovery room and wants to breastfeed her baby. What would be your best action?
a. Advise her that breastfeeding is contraindicated for now because of the effects of the anesthesia.
b. Advise her that breastfeeding is temporarily not possible because it will increase her incision pain.
c. Assist her with breastfeeding because this also helps reduce uterine bleeding postpartally.
d. Urge her to wait until she’s transferred to a postpartum bed.
FILL IN THE BLANK QUESTIONS:

19. When fetal membranes are artificially ruptured during labor, this is termed __Amniotomy__.
20. A vaginal birth after a cesarean birth is abbreviated as ____VBAC____.
MULTIPLE RESPONSE QUESTIONS:

21. What assessments should you perform prior to a cesarean birth? (Select all that apply.)
a. Fetal heart rate (FHR)
b. Maternal blood pressure
c. Maternal anxiety level
d. Urine for analysis
e. Presence of an identification band
22. What would you want Linda to know are possible outcomes of a planned cesarean birth? (Select all
that apply.)
a. She will be taught to tolerate her postsurgical pain.
b. She will have a small vertical incision on her abdomen.
c. Injury to her urinary or intestinal tract could potentially occur.
d. Blood clots in her lower extremities could develop.
e. Infection is a possibility following any type of surgery.
f. It will take a day or two for normal bowel function to return.
23. Based on the QSEN competency for safety, what preoperative teaching would you provide to help
Linda prevent postcesarean birth complications? (Select all that apply.)
a. The technique for doing periodic deep breathing exercises
b. Reasons for using an incentive spirometer should be used postoperatively
c. Strategies for maintaining strict bed rest to conserve energy
d. Technique for performing hourly uterine massage
e. Ways of maximizing her food intake postoperatively
Powered by TCPDF (www.tcpdf.org)

CH 24 CS PT Scenario

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

CH 24 CS PT Scenario

Uploaded by

Copyright:

Available Formats

Patient Scenario, Chapter 24, Nursing Care of a Family During a

Surgical Intervention for Birth

A WOMAN HAVING A CESAREAN BIRTH

HISTORY OF CHIEF CONCERN:

HISTORY OF PAST ILLNESSES:

HISTORY OF FAMILY ILLNESSES:

FILL IN THE BLANK QUESTIONS:

20. A vaginal birth after a cesarean birth is abbreviated as VBAC.

MULTIPLE RESPONSE QUESTIONS:

You might also like