A nurse is assisting with the plan of care for a client who is in the third trimester of pregnancy and has ankle edema. Which of the following interventions should the nurse include in the client's plan of care?
Administer diuretics.
Place on bedrest
Limit fluid intake.
Apply support stockings.
The Correct Answer is D
Answer: D. Apply support stockings.
Rationale: Support stockings can help reduce ankle edema by promoting venous return and preventing fluid accumulation in the lower extremities. Diuretics, bedrest, and fluid restriction are not recommended for pregnant clients with ankle edema as they can cause dehydration, thromboembolism, and fetal compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choiceb. Place the client in Trendelenburg position.
Choice A rationale:
Loosely wrapping the cord with petroleum gauze is not recommended.Instead, the cord should be wrapped with sterile saline-soaked gauze to prevent it from drying out and to minimize infection risk.
Choice B rationale:
Placing the client in Trendelenburg position helps to relieve pressure on the prolapsed cord by using gravity to shift the fetus away from the pelvis. This position helps to improve blood flow through the umbilical cord until delivery can be arranged.
Choice C rationale:
Evaluating uterine tone is not directly related to managing a prolapsed umbilical cord.The priority is to relieve pressure on the cord to prevent fetal hypoxia.
Choice D rationale:
Applying fundal pressure is contraindicated as it can increase pressure on the prolapsed cord, worsening the situation.
Correct Answer is A
Explanation
The correct answer is A. Clean the wound from the center to the outer edges.
Rationale: The nurse should clean the wound from the center to the outer edges to prevent contamination of the wound bed by bacteria or debris from the surrounding skin. The nurse should wear clean gloves, not sterile gloves, to remove the dressing, as wet-to-dry dressings are not sterile and do not require a sterile technique.
The nurse should remove the tape by pulling parallel to and away from the skin, not from the center of the dressing, to minimize skin damage and pain. The nurse should not moisten the dressing before removal, as this would defeat the purpose of wet-to-dry dressings, which are intended to debride necrotic tissue by adhering to it and pulling it off when dry.
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