The nurse is caring for a client who had a cesarean birth 4 hours ago. Which interventions would the nurse implement at this time? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply
1. Administer analgesics as needed.
2. Encourage the client to ambulate to the bathroom to void.
3. Encourage leg exercises every 2 hours.
4. Encourage the client to cough and deep-breathe every 2 to 4 hours.
5. Encourage the use of breathing, relaxation, and distraction.
1, 3, 4, 5
Explanation: 1. The nurse continues to assess the woman's pain level and provide relief measures as needed.
3. Within the first 12 hours postoperatively, unless medically contraindicated, the woman should be assisted to dangle her legs on the side of the bed.
4. The woman is encouraged to cough and breathe deeply and to use incentive spirometry every 2 to 4 hours while awake for the first few days following cesarean birth.
5. The nurse should encourage the use of breathing, relaxation, and distraction techniques.
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