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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Fundal consistency is correct, as this finding can indicate the effectiveness of oxytocin in stimulating uterine contraction and preventing postpartum hemorrhage. Oxytocin is a uterotonic agent that can enhance or augment uterine contractility and involution. The nurse should monitor the fundal height, consistency, and position and report any signs of uterine atony or excessive bleeding.
Choice B reason: Fetal heart rate is incorrect, as this finding is not relevant for a client who has already delivered the baby. Fetal heart rate can indicate the fetal well-being and response to labor, but it is not affected by oxytocin administration after birth. The nurse should monitor the newborn's vital signs and appearance and report any signs of distress or infection.
Choice C reason: Pulse rate is incorrect, as this finding is not specific for evaluating the effectiveness of oxytocin. Pulse rate can indicate the client's hemodynamic status and response to blood loss, but it can be influenced by many other factors, such as pain, anxiety, fever, or dehydration. The nurse should monitor the client's vital signs and fluid balance and report any signs of shock or infection.
Choice D reason: Urinary output is incorrect, as this finding is not specific for evaluating the effectiveness of oxytocin. Urinary output can indicate the client's renal function and fluid balance, but it can be influenced by many other factors, such as fluid intake, bladder distension, or epidural anesthesia. The nurse should monitor the client's intake and output and report any signs of oliguria or retention.
Choice E reason: Blood pressure is incorrect, as this finding is not specific for evaluating the effectiveness of oxytocin. Blood pressure can indicate the client's hemodynamic status and response to blood loss, but it can be influenced by many other factors, such as pain, anxiety, preeclampsia, or medication. The nurse should monitor the client's vital signs and fluid balance and report any signs of hypotension or hypertension.
Correct Answer is A
Explanation
Choice A reason:
Panting can help prevent premature pushing and reduce the risk of cervical edema or laceration. The client should be instructed to take short, shallow breaths through her mouth during contractions until she reaches 10 cm of dilation.
Choice B reason:
Assessing the perineum for signs of crowning is not a priority at this stage, as the fetus is not yet at a low enough station to be visible. Crowning usually occurs when the fetus is at +4 or +5 station.
Choice C reason:
Assisting the client into a comfortable position is important, but it does not address the urge to push. The client should be encouraged to change positions frequently to promote fetal descent and comfort.
Choice D reason:
Helping the client to the bathroom to empty her bladder is not advisable, as it can increase the risk of cord prolapse or rupture of membranes. The client should have an indwelling catheter inserted if she is unable to void spontaneously.
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