A client who is 7 days postpartum calls the provider's office and reports pain, swelling, and redness of her left calf. Besides the client seeing the provider, which of the following interventions should the nurse suggest?
Massage the area.
Apply cold compresses
Flex the knee while resting
Elevate the leg
The Correct Answer is D
Choice A rationale:
Massaging the area is not recommended because the client's symptoms could indicate a possible deep vein thrombosis (DVT), and massaging could dislodge a clot and cause harm.
Choice B rationale:
Applying cold compresses is not recommended if DVT is suspected, as it could potentially worsen the condition.
Choice C rationale:
Flexing the knee while resting is not recommended if DVT is suspected, as it could potentially worsen the condition and increase the risk of a clot traveling to the lungs (pulmonary embolism).
Choice D rationale:
Elevating the leg can help reduce swelling and improve blood flow. However, the client should still see the provider for further evaluation of possible DVT.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Weight loss in the first few days after birth is normal for newborns, and a weight loss of up to 7-10% of the birth weight is considered within the expected range. A 6% weight loss is within normal limits, and it is reassuring to inform the mother that this is typical.
Choice B rationale: Suggesting switching to formula is not necessary based on the weight loss described. Breastfeeding provides adequate nutrition for most newborns, and early weight loss is typical and not a cause for alarm.
Choice C rationale: While it is true that new mothers may worry about breastfeeding and milk supply, this response does not address the specific weight loss concern and might not fully reassure the mother.
Choice D rationale: A 6% weight loss is within the expected range for a newborn and does not warrant hospitalization. It is a normal finding, and most newborns will start to regain their birth weight within a few days of life.
Correct Answer is B
Explanation
Choice A rationale:
Administering the hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen is not the appropriate treatment for a newborn whose mother is positive for the hepatitis B surface antigen. Immediate intervention is required to prevent transmission.
Choice B rationale:
The newborn of a mother who is positive for the hepatitis B surface antigen should receive hepatitis B immune globulin (HBIG) and the hepatitis B vaccine within 12 hours of birth. HBIG provides passive immunity to the baby while the vaccine stimulates active immunity.
Choice C rationale:
Administering hepatitis B immune globulin for 1 week followed by the hepatitis B vaccine monthly for 6 months is not the correct treatment plan. Immediate intervention is necessary to prevent transmission to the newborn.
Choice D rationale:
Administering the hepatitis B vaccine at 24 hours followed by hepatitis B immune globulin every 12 hours for 3 days is not the appropriate treatment. Hepatitis B immune globulin should be given within 12 hours of birth, not over several days.
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