The nurse is caring for a patient who had a cesarean birth 4 hours ago. Which of the following interventions would the nurse implement at this time?
1. Administer analgesics as needed.
2. Encourage the patient to ambulate to the bathroom to void.
3. Encourage leg exercises every 2 hours.
4. Encourage the patient to cough and deep-breathe every 2–4 hours.
5. Encourage the use of breathing, relaxation, and distraction.
Correct Answer: 1,3,4,5
Rationale 1: Administering analgesics as needed, encouraging leg exercises every 2 hours, encouraging the patient to cough and deep-breathe every 2–4 hours, and encouraging the use of breathing, relaxation, and distraction all address the patient's nursing care needs, which are similar to those of other surgical patients.
Rationale 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 4 hours.
Rationale 3: Administering analgesics as needed, encouraging leg exercises every two hours, encouraging the patient to cough and deep-breathe every 2–4 hours, and encouraging the use of breathing, relaxation, and distraction all address the patient's nursing care needs, which are similar to those of other surgical patients.
Rationale 4: Administering analgesics as needed, encouraging leg exercises every two hours, encouraging the patient to cough and deep-breathe every 2–4 hours, and encouraging the use of breathing, relaxation, and distraction all address the patient's nursing care needs, which are similar to those of other surgical patients.
Rationale 5: Administering analgesics as needed, encouraging leg exercises every two hours, encouraging the patient to cough and deep-breathe every 2–4 hours, and encouraging the use of breathing, relaxation, and distraction all address the patient's nursing care needs, which are similar to those of other surgical patients.
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