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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Feeling for a full bladder is not the first action the nurse should take, although it is important to assess for bladder distension and urinary retention in postpartum clients. A full bladder can displace the uterus and increase the risk of uterine atony and hemorrhage.
Choice B reason:
Checking the client's fundus is the first action the nurse should take, as it can indicate the tone and position of the uterus. A firm and midline fundus indicates adequate uterine contraction and prevents excessive bleeding. A boggy or deviated fundus indicates uterine atony or retained placental fragments, which can cause hemorrhage.
Choice C reason:
Measuring the client's vital signs is not the first action the nurse should take, although it is important to monitor for signs of shock and infection in postpartum clients. Vital signs can be affected by various factors and do not provide a direct assessment of uterine status.
Choice D reason:
Requesting the provider perform a vaginal examination is not the first action the nurse should take, as it can introduce infection and trauma to the perineum. A vaginal examination is only indicated if there is suspicion of cervical or vaginal lacerations or retained placenta.
Correct Answer is D
Explanation
Choice A reason: Amniotic fluid in the vaginal vault indicates that the membranes have ruptured, but this does not necessarily mean that the client is in labor. Some women may have a slow leak of amniotic fluid for hours or days before labor begins. Rupture of membranes also increases the risk of infection, so the nurse should monitor the client's temperature and fetal heart rate.
Choice B reason: Contractions every 3 to 4 minutes are a sign of labor, but they are not enough to confirm it. The nurse should also assess the duration and intensity of the contractions, as well as the client's response to them. Some women may have false labor contractions, also known as Braxton Hicks contractions, which are irregular, mild, and do not cause cervical changes.
Choice C reason: Pain just above the navel is not a typical sign of labor. It may indicate other problems, such as placental abruption, uterine rupture, or fetal distress. The nurse should report this finding to the nurse midwife and check for other signs of bleeding, shock, or fetal compromise.
Choice D reason: Cervical dilation is the most reliable indicator of labor. It means that the cervix is opening and thinning out to allow the passage of the fetus. The nurse should measure the cervical dilation in centimeters and document it along with the station and effacement of the cervix.
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