A client who was in labor for 32 hours gave birth to a healthy newborn by emergency

cesarean section. Which statement by this client would alert the nurse that the client is
having problems with her self-esteem?
- "I feel like I'm not a real mother because I could not give birth to my baby the
natural way."
The health care provider has ordered a cesarean birth for an exhausted client who has
been in labor for many hours with the fetus now showing increasing signs of distress. As
the client and partner express disappointment in not having a natural birth (and anxiety
in not knowing what will now happen), which response will the nurse prioritize?
- Briefly describe what will be experienced, explain each procedure, and
encourage the partner to participate.

A pregnant client tells the nurse, “Labor and birth sounds so awful. Can’t I just schedule
a cesarean birth instead?” How will the nurse reply?
- "Can you tell me more about your concerns regarding the labor and birth
processes?"
The nursing instructor is teaching a group of student nurses about the current use of
episiotomies during the labor process. The instructor determines the session is
successful when the students correctly choose which situation that may require the
health care provider to perform an episiotomy?
- shoulder dystocia
A client is being prepared for a scheduled cesarean birth by the medical team. Which
intervention will be most critical for the team to monitor in the first 24 hours post-
cesarean birth?
- urinary output
A client who planned an unmedicated vaginal birth at a freestanding birth center is
transferred to the hospital for a cesarean birth due to cephalopelvic disproportion. The
client says to the nurse, “I feel like such a failure. I could not even give my baby the
gentle start that I wanted!” How does the nurse respond?
- "It sounds like you are disappointed by the outcome of the birth. Would you like
to talk more about this?"
The nurse is monitoring a client at 41 weeks' gestation receiving IV oxytocin. Which
action should the nurse prioritize if noticeable contractions are occurring every 2
minutes, lasting 60 to 90 seconds on the fetal monitor?
- Stop the IV oxytocin infusion.
A nurse is assisting with preparations for a cesarean birth due to nonprogression during
labor. The surgeon has arrived, as has the anesthesiologist, a student assistant to the
surgeon, and multiple nurses. To whom will the nurse hand the informed consent
paperwork, to be completed prior to the procedure?
 - Surgeon
Which of the following measures is the most effective way for the nurse to assist the
woman recovering from cesarean birth to stimulate lower extremity circulation?
- Help the woman to ambulate as soon as possible.
The nurse is instructing a primipara who has concerns about the need for a cesarean
birth due to her sister's obstetrical history. Which statement by the client needs further
instruction?
- "My sister had a cesarean birth with the first infant and now needs it for all
subsequent pregnancies."
The nurse has received the beginning-of-shift report for five clients. With which
conditions will the nurse anticipate a cesarean birth? Select all that apply.
- A classical uterine scar
- Placenta previa
- Active vaginal or cervical herpes lesions
A nurse is preparing a client for a scheduled cesarean birth. The client is getting on the
stretcher to move from the admission room to the surgical suite. When placing the client
on the stretcher, which nursing intervention will be helpful to prevent supine hypotension
syndrome in the client?
- Have the client lie on the left side during transport.
The client has been progressing well through the labor process and the health care
provider prepares to deliver the infant and performs an episiotomy. The nurse predicts
which situation is the reason for this procedure?
- shoulder dystocia
The nursing instructor is conducting a class presenting the various aspects of a
cesarean birth. The instructor determines the class is successful after the students
correctly choose which complication as the most common postoperative complication?
- Infection
At 0500 hrs, a client was started on oxytocin. The nurse notes on assessment the client
is dilated to 4 cm with contractions every 1 minute and increased signs of fetal distress.
What action should the nurse prioritize after noting the time is now 1200 hrs?
- Stop the oxytocin infusion.
The pain management plan for a client who is scheduled for a cesarean birth indicates
that patient-controlled analgesia will be used postoperatively. When discussing this type
of pain relief, the client asks, “Is this is an effective way to control pain?” Which
response by the nurse is appropriate?
- “It has been shown to be effective and also helps lower the amount of pain
medicine used.”
The nurse is assessing a neonate after a cesarean birth. Which most common
complication should the nurse be prepared for?
- respiratory distress
The nurse is caring for a client who is being prepared for a cesarean birth due to
nonprogession of the labor process. The nurse will direct the client to the proper
placement on the operating table and abdominal preparation for which type of incision?
- low transverse incision ("bikini cut")
A client is undergoing an amniotomy during labor. Which of the following complications
associated with this intervention should the nurse be most prepared to address?
- cord prolapse
The nurse is caring for a client who had a cesarean birth 3 days ago (above). What
complication does the nurse suspect?
- peritonitis
To prevent tearing of the perineum of a client during birth, a physician performs a
mediolateral episiotomy. The nurse recognizes that an advantage of a mediolateral
episiotomy over a midline episiotomy is which of the following?
- lower rlsk for rectal mucosal tear
A client in labor has just been told that she must have an emergency cesarean birth.
The nurse is aware that the surgery is likely to be completed within what time frame? Fill
in the blank with a number of minutes.
- 30
A nurse manager is conducting an in-service education program on cesarean birth for
the labor and delivery staff of the facility. After teaching the class, the nurse manager
determines that the teaching was successful when the students identify which factor as
an indication for cesarean birth? Select all that apply
- Active genital herpes
- Cervical cerclage
- Multiple gestation
When an infant is born by cesarean delivery there is always a risk of complications.
What is one of the most common complications to the fetus because of a cesarean
delivery?
- Respiratory distress
A nurse correctly recognizes which of the following as a current trend within the
population of birthing women?
- increased rates of cesarean sections
A 35-year-old P1001 has been admitted for a scheduled repeat cesarean. As the nurse
prepares the client for surgery, what is the best way to begin preoperative teaching?
- Assess how much the woman already knows about cesarean.
While the nurse is assessing the prenatal client’s understanding of the information
provided at a recent appointment, the client states, “I want to avoid the pain and long
hours of labor, so I’m electing to have a cesarean birth.” How should the nurse
respond?
- “A cesarean birth is a method to be used when vaginal birth is not possible—it is
not a true option.”
The client plans to undergo a vaginal birth after cesarean (VBAC) and has recently
begun labor. The labor nurse is following the fetal monitor closely. The results of which
monitoring will best help the nurse assess contraction strength in the client?
- internal electronic monitoring
An obese client gave birth via cesarean with sutures applied at the surgical incision site.
The nurse is concerned that the client's obesity will make it difficult to achieve which
postpartum outcome?
- healing at the site of incision
When providing discharge education to a client who has had a cesarean birth, which
information will the nurse include?
- restrictions to lift nothing heavier than the infant
A nurse is inserting a urinary catheter into a client about to undergo a cesarean birth.
The client asks, "Why is this necessary? I can empty my bladder in the bathroom." How
will the nurse accurately respond?
- "This measure will help keep your bladder drained and away from the site of
surgery."
The nurse cares for a client scheduled for a cesarean birth for a breech presentation.
The client requests general anesthesia instead of regional anesthesia for the procedure
because of increased anxiety about being awake during the surgery. How does the
nurse respond?
- "Can you tell me more about what you are concerned about during the surgery?"
A woman has just arrived to the recovery room after an emergency cesarean birth and
is anxious to begin breastfeeding her baby. What is the best response from the nurse?
- "Sure, let me help you with that."
The client is 6 hours postoperative from a cesarean birth where epidural morphine was
administered. What assessment(s) will the nurse complete related to this medication?
Select all that apply.
- Respiratory rate
 - Oxygen saturation
- Level of consciousness
Eight hours after a cesarean section, a postpartum woman is having heavy lochia. She
informs the nurse, who suspects which of the following causes?
- postpartum hemorrhage
When counseling a client about maternal risks and benefits of cesarean birth, which of
the following would not apply?
- "A surgical incision may be made at the perineum to enlarge the vagina just
before the birth of the baby."
A nurse is caring for a client who requires a cesarean birth because of labor dystocia.
The woman’s husband signs the consent form. Which of the following individuals is
responsible for obtaining the informed consent prior to a cesarean birth?
- Physician
Place the following events in order of occurrence for administration of spinal anesthesia
before an elective primary cesarean birth in a woman who is not in labor.
- The woman enters the OR
- The nurse instructs the client to sit and make a C-curve with her back.
- The anesthesiologist cleanses the back.
- Spinal anesthesia is administered.
- The client lies down on the delivery table, and a wedge is placed.
A client in labor has just learned that she will have to undergo a cesarean birth due to
failure to progress. The woman looks frightened and stressed. Which of the following is
a physiological stress response that the nurse would expect to see in such a client?
- peripheral vasoconstriction
How should the nurse counsel a client who has arrived for a scheduled repeat cesarean
birth?
- "An IV catheter will be placed, and we will do some preoperative blood work.
Then we will give you some antibiotics.
During preoperative teaching for a client about to undergo a cesarean birth, the nurse is
instructing on how to do deep-breathing exercises. Which client symptom confirms that
further instruction is needed?
- light-headedness following exhalations
What is the most effective way to stimulate circulation after cesarean birth?
- ambulation within 4 hours of birth
The nurse is caring for a woman during and following a cesarean birth. When
completing an intake and output form, which range of blood loss would the nurse
document and view as anticipated for this procedure?
 - 500 to 1000 ml
The nurse is caring for a client who underwent a cesarean birth 2 days ago. Which
statment by the client demonstrates the need for further education about postoperative
recovery and care?
- "I will carry the baby in the car seat between the car and the house."
A client underwent a cesarean birth due to fetal distress. The medical records reflect a
low transverse uterine incision was used. When speaking with the nurse, the client
questions her ability to give birth vaginally with her next pregnancy. What response by
the nurse is most appropriate?
- "Having a cesarean birth does not mean you will have a cesarean birth with
future births."
What is not part of the discharge planning for a woman who has had a cesarean birth?
- "If you have any vaginal bleeding, you should contact your health care provider."
A 21-year-old has been in labor for 4 hours; her examination 2 hours ago revealed 6
cm/100%/-3. During a contraction, she spontaneously ruptures her membranes. The
doctor checks the patient, finds her to be 9 cm/100%/-3, and states that the cord is
palpable. What should the nurse do?
- Call for help and prepare the client for an emergency cesarean birth.
The nurse is caring for a client for whom a cesarean birth is indicated. The client is
currently preoperative. Which client concern(s) should be addressed in the plan of care?
Select all that apply
- Feer related to impending surgery
- Powerlessness related to medical need for cesarean birth
- Risk for anxiety related to unanticipated circumstances surrounding birth
The nurse is teaching a prenatal class about a cesarean birth. What benefit of a uterine
incision should the nurse point out in the teaching?
- least likely to rupture during subsequent labors
A client in labor had no change in cervical dilation (dilatation) over the past 2 hours. The
health care provider performs an amniotomy. Based on the chart above, what should
the nurse do first after the amniotomy?
- Assess fetal heart rate.
A new mother calls the clinic on her fourth day after delivery and reports difficulty
urinating and defecating because of the perineal pain. What does the nurse suspect is
causing these problems?
- episiotomy
A client is 3 hours post-cesarean delivery. The nurse notes the Foley catheter bag has
30 ml of urine and it has been 2 hours since it was last checked. What is the appropriate
nursing intervention?
- Check the Foley tubing.
A woman has just entered the recovery room after cesarean birth of a baby weighing 9
lb 14 oz. After connecting the client to the blood pressure monitor, it is noted her heart
rate (HR) is 120 and blood pressure (BP) is 80/40. What nursing action should be a
priority?
- assess for bleeding
The nurse is preparing a client for an emergent cesarean delivery. Which action should
the nurse prioritize?
- Sign informed consent.
The nurse is caring for a client following a cesarean birth who received a low segment
incision. Which outcome is possible for the client?
- experiencing vaginal delivery during future births
What will the nurse include in the care plan of a client who underwent cesarean birth to
reduce the risk of postoperative urinary tract infection?
- removal of indwelling catheter as soon as possible
A client with limited prenatal care presents in labor and is requesting a VBAC. What is
the nurse's response after verifying the client had a classical incision with the last
cesarean birth?
- "Based on your history, a vaginal delivery is not recommended, it might cause
your uterus to rupture."
A pregnant client who had a previous cesarean birth for breech presentation is planning
a vaginal birth and asks the nurse how to increase the chances of having a vaginal
birth. What will the nurse include in the response? Select all that apply
- Hire a doula for labor support
- Seek out nurse-midwife care
The nurse is preparing a pregnant female for an unexpected emergency cesarean birth.
The client expresses concern and fear for the procedure. Which nursing intervention is
best for this client?
- Acknowledge the client’s feelings and be empathic.
A pregnant client is discussing birth options with the nurse. The client previously had a
cesarean birth with a classic incision at 26 weeks' gestation but desires a vaginal birth
with this pregnancy. Which response by the nurse explains the potential for a vaginal
birth for this client?
 - "With a classical incision there is an increased risk of uterine rupture in labor, so
a vaginal birth is not usually recommended."
A client at 38 weeks' gestation is being prepared for an emergency cesarean birth due
to uterine cramping with bright red-tinged vaginal drainage. Vital signs upon admission
are temperature of 36.6°C (97.9°F), heart rate of 92 beats/min, respiratory rate of 24
breaths/min, and blood pressure at 140/76 mm Hg. The client reports the following
morning data: ingested a breakfast sandwich and milk 3 hours ago, voided, no bowel
movement this morning. Which action will the nurse expect to complete for this client?
- administering metoclopramide
A client who underwent cesarean birth 7 days ago comes to the clinic for assessment
(above). What assessment finding(s) will the nurse report to the primary health care
provider for this client? Select all that apply.
- Temperature
- Incisional drainage
- Erythema
A nurse is providing care to a client who had a cesarean birth at 11 AM. It is now 1 PM.
The nurse would assess the client at which frequency?
- Every 30 minutes
The client is 4 hours post-cesarean birth and is assessed by the nurse (above). What
action will the nurse take first?
- Assess the catheter for kinks or occlusion.
A nurse assisting in a cesarean birth should essentially demonstrate understanding of
which of the following?
- skill in either a scrubbing or circulating role
A client in labor is to undergo an amniotomy. When assisting with the procedure, the
nurse would have the client assume which position?
- dorsal recumbent
A woman arrives at labor and delivery unit with contractions every 2–3 minutes lasting
30–45 seconds. After several hours of labor have passed and not making progress, the
health care provider prepares to perform an amniotomy. The woman asks the nurse,
"How will this help my labor?" Which response by the nurse would be appropriate?
- "With this procedure, your body sends out hormones that make labor more
effective."
According to the National Vital Statistics System (NVSS), what was the national
cesarean rate in 2014?
- 32%
The nurse is caring for a client who is receiving epidural analgesia with morphine
following cesarean birth. For which side effects should the nurse monitor? Select all that
apply.
- Itching
- Nausea
- Vomiting
A nurse is preparing to teach a client about her potential cesarean birth and explains the
possible incisional locations. Which information should the nurse include when pointing
out the most common type of incision is the low transverse method?
- Minimizes blood loss
The nurse is caring for a 45-year-old client who will undergo cesarean birth. Which age-
related finding should the nurse treat to reduce the client’s surgical risk?
- gestational diabetes
A nurse is developing the plan of care for a client who has just had a cesarean birth
using a low transverse incision ("bikini cut"). The client's membranes ruptured 15 hours
ago. Which medication would the nurse anticipate being prescribed for this client?
- cefazolin
The pregnant client and her partner have arrived for a scheduled cesarean birth. Which
action should the nurse prioritize?
- Obtain laboratory specimens.
A woman is being seen in the clinic for care during her first pregnancy and birth. The
nurse will educate this woman and her significant other about their planned cesarean
birth and what can be expected. When should the nurse provide this family education?
- each time the nurse sees the woman before surgery
There is much discussion in the medical community about vaginal birth after a cesarean
delivery (VBAC). When a woman has had a previous emergency cesarean delivery, she
is at high risk for a ruptured uterus. When is VBAC contraindicated?
- when a classical uterine incision has been made previously
The nurse is conducting a prenatal class for a group of pregnant women and their
partners. When illustrating the various potential complications that can necessitate a
cesarean birth, which primary reason should the nurse point out?
- Nonreassuring fetal status