The nurse is planning care for a client who had a cesarean birth 4 hours ago. Which actions should be included in this client's plan of care? Select all that apply
A) Encourage the use of breathing, relaxation, and distraction.
B) Encourage deep breathing and coughing every 2 to 4 hours.
C) Encourage to ambulate to the bathroom to void.
D) Discourage leg exercises.
E) Withhold all analgesics.
Answer: A, B
Encouraging deep breathing and coughing every 2 to 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. Encouraging the client 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. Leg exercises should be encouraged. Withholding analgesics may leave the client in pain.
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