The nurse is providing care to a client who gave birth to a newborn by cesarean section. When providing care to this client, which nursing actions are appropriate? Select all that apply
A) Encouraging coughing and deep breathing every 2 hours until the client is able to ambulate
B) Monitoring the episiotomy site every shift
C) Encouraging the client to lay on the right side to promote passing gas
D) Assessing bowel sounds every 8 hours
E) Assessing the client hourly while receiving a continuous epidural infusion
Answer: A, E
Appropriate nursing actions when providing care to a client who gave birth by cesarean section includes encouraging coughing and deep breathing every 2 hours until the client is able to ambulate and assessing the client hourly while receiving a continuous epidural infusion. The client will not have an episiotomy after a cesarean birth; however, the nurse would monitor the abdominal incision. The nurse would monitor bowel sounds but the frequency is every 4 hours, not every 8 hours. The nurse would encourage the client to lie on the left side, not the right side, to promote the passing of gas.
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