The nurse is caring for a client who had a cesarean birth four hours ago. Which of the following interventions would the nurse implement at this time? 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 two hours.
4. Encourage the client to cough and deep-breathe every 2–4 hours.
5. Encourage the use of breathing, relaxation, and distraction.
1, 3, 4, 5
Rationale:
1. Administering analgesics as needed, encouraging leg exercises every two hours, encouraging the client to cough and deep-breathe every 2–4 hours, and encouraging the use of breathing, relaxation, and distraction all address the client's nursing care needs, which are similar to those of other surgical clients.
2. Encouraging her to ambulate to the bathroom to void might be an intervention done on the first or second day postpartum, but not in the first four hours.
3. Administering analgesics as needed, encouraging leg exercises every two hours, encouraging the client to cough and deep-breathe every 2–4 hours, and encouraging the use of breathing, relaxation, and distraction all address the client's nursing care needs, which are similar to those of other surgical clients.
4. Administering analgesics as needed, encouraging leg exercises every two hours, encouraging the client to cough and deep-breathe every 2–4 hours, and encouraging the use of breathing, relaxation, and distraction all address the client's nursing care needs, which are similar to those of other surgical clients.
5. Administering analgesics as needed, encouraging leg exercises every two hours, encouraging the client to cough and deep-breathe every 2–4 hours, and encouraging the use of breathing, relaxation, and distraction all address the client's nursing care needs, which are similar to those of other surgical clients.
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