A nurse is caring for a client who is 1 day postpartum following a cesarean birth. To prevent thrombophlebitis, the nurse should contribute which of the following interventions to the client's plan of care?

Apply warm, moist soaks to the client's lower legs.

Have the client ambulate frequently in the hallway.

Keep the client on bed rest.

Place pillows under the client's knees while she is resting in bed.

Answer and Explanation

The Correct Answer is B

Choice A reason: Apply warm, moist soaks to the client's lower legs is incorrect, as this action is not eﬀective for preventing thrombophlebitis. Warm, moist soaks can provide comfort and reduce inﬂammation, but they do not improve blood circulation or prevent clot formation.

Choice B reason: Have the client ambulate frequently in the hallway is correct, as this action can prevent thrombophlebitis by improving venous return and preventing stasis. The nurse should encourage and assist the client to ambulate early and frequently after a cesarean birth, as long as there are no contraindications. The nurse should also monitor the client for signs of orthostatic hypotension and provide support as needed.

Choice C reason: Keep the client on bed rest is incorrect, as this action can increase the risk of thrombophlebitis by reducing blood ﬂow and promoting stasis. Bed rest can also delay wound healing and increase the risk of infection and deconditioning. The nurse should avoid keeping the client on bed rest unless absolutely necessary.

Choice D reason: Place pillows under the client's knees while she is resting in bed is incorrect, as this action can impair blood circulation and increase the risk of thrombophlebitis. Placing pillows under the knees can cause pressure on the popliteal veins and reduce venous return. The nurse should advise the client to avoid crossing their legs or placing pillows under their knees while resting in bed.

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Correct Answer is D

Explanation

Choice A reason: Swelling in both breasts is incorrect, as this finding does not indicate mastitis. Swelling in both breasts can occur due to engorgement, which is a normal and expected phenomenon in the first few days after birth or when milk production increases. Engorgement can cause breast fullness, tenderness, and warmth, but it does not cause infection or inﬂammation.

Choice B reason: Cracked and bleeding nipples is incorrect, as this finding does not indicate mastitis. Cracked and bleeding nipples can occur due to poor latch, improper positioning, or excessive suction of the baby. Cracked and bleeding nipples can cause pain, discomfort, and risk of infection, but they do not cause mastitis by themselves.

Choice C reason: Increase in breast milk is incorrect, as this finding does not indicate mastitis. Increase in breast milk can occur due to hormonal changes, frequent breastfeeding, or stimulation of the breasts. Increase in breast milk can cause engorgement, but it does not cause infection or inﬂammation.

Choice D reason: Red and painful area in one breast is correct, as this finding indicates mastitis. Mastitis is an infection and inﬂammation of the breast tissue that usually aﬀects one breast at a time. Mastitis can cause redness, pain, swelling, warmth, and fever in the aﬀected breast. Mastitis can occur due to blocked milk ducts, bacterial invasion, or poor hygiene. The nurse should advise the client to continue breastfeeding or pumping, apply warm compresses, massage the breast gently, and take antibiotics as prescribed.

A. Massage the client's fundus. B. Check the client's blood pressure. C. Administer oxytocin. D. Observe for pooling of blood under the butocks.

Correct Answer is A

Explanation

Choice A reason: Massage the client's fundus is correct, as this is the first action the nurse should take according to the ABCDE priority framework. Saturating a perineal pad in 10 min indicates excessive bleeding and possible postpartum hemorrhage, which can compromise the client's airway, breathing, and circulation. Massaging the fundus can stimulate uterine contraction and reduce blood loss.

Choice B reason: Check the client's blood pressure is incorrect, as this is not the first action the nurse should take, although it is important to monitor for signs of shock. Checking the blood pressure does not address the cause of bleeding or prevent further blood loss.

Choice C reason: Administer oxytocin is incorrect, as this is not the first action the nurse should take, although it may be indicated later. Administering oxytocin requires a provider's order and may have adverse eﬀects such as nausea,

vomiting, headache, or water intoxication. The nurse should first atempt to control bleeding by massaging the fundus and then administer oxytocin as ordered.

Choice D reason: Observe for pooling of blood under the butocks is incorrect, as this is not the first action the nurse should take, although it can help estimate blood loss. Observing for pooling of blood does not address the cause of bleeding or prevent further blood loss. The nurse should first atempt to control bleeding by massaging the fundus and then assess for other signs of hemorrhage.

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A nurse is caring for a client who is 1 day postpartum following a cesarean birth. To prevent thrombophlebitis, the nurse should contribute which of the following interventions to the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postpartum and is breastfeeding her infant. Which of the following findings indicates mastitis?

Correct Answer is D

Explanation

A nurse is caring for a postpartum client who saturates a perineal pad in 10 min. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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A nurse is collecting data from a postpartum client and notes the client's fundus is boggy and displaced to the right. Which of the following actions should the nurse take?