A nurse is caring for a client who is 1 hr postpartum.

Nurses' Notes 1200:

Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus. Oxytocin 20 units being administered via continuous JV infusion.

1215:

Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified.

Select the actions the nurse should take.

Choice A rationale:

Massaging the legs before applying the stockings is not advisable. Vigorous massage can dislodge clots in patients with DVT, leading to serious complications like pulmonary embolism. It is essential to handle the legs gently and follow the proper procedure for applying antiembolitic stockings.

Choice B rationale:

Folding the stockings at the top if they are too long is not recommended. Altering the stockings in this way can create uneven pressure, reducing their effectiveness in preventing DVT. It is crucial to choose the correct size of stockings to ensure proper compression and prevention of complications.

Choice C rationale:

Measuring the legs with a tape measure to determine the stocking size is the correct action. Proper sizing is essential to ensure the stockings fit the patient correctly and provide the appropriate level of compression. Ill-fitting stockings can be ineffective and may even cause harm, such as skin abrasions or impeded circulation.

Choice D rationale:

Removing the stockings every 24 hours is unnecessary unless there is a specific medical indication to do so. Continuous wear of antiembolitic stockings is generally recommended to provide consistent compression and prevent deep-vein thrombosis (DVT)

How does this make you feel?

• A. Saying "I'm sure your family does not want you to die" is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's assumption on the client. This option is incorrect.
• B. Asking "Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, and may make the client feel defensive or ashamed. This option is incorrect.
• C. Asking "How does this make you feel?" is a therapeutic response, as it encourages the client to express their emotions and shows empathy and interest from the nurse. This option is correct.
• D. Saying "You should talk to your family about your feelings" is not a therapeutic response, as it implies that the client is responsible for resolving their family issues and may increase their guilt or anxiety. This option is incorrect.