A nurse is caring for a postpartum client who had a cesarean birth.
Which of the following actions should the nurse take to prevent DVT in this client?
Apply a heating pad to the lower legs.
Encourage early and frequent ambulation.
Place a pillow under the knees when in bed.
Massage the affected limb gently.
The Correct Answer is B
The correct answer is choice B. Encourage early and frequent ambulation. This action helps to prevent DVT by keeping the blood flowing in the lower legs and reducing venous stasis. Early and frequent ambulation is also recommended by various clinical guidelines for postpartum VTE prevention.
Choice A is wrong because applying a heating pad to the lower legs does not prevent DVT and may increase the risk of bleeding or infection.
Choice C is wrong because placing a pillow under the knees when in bed does not prevent DVT and may worsen venous stasis by compressing the iliac veins.
Choice D is wrong because massaging the affected limb gently does not prevent DVT and may dislodge a clot or cause damage to the vein wall.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
The correct answer is choice A, B, D and E. These are measures to prevent thrombophlebitis, which is a condition where a blood clot forms in a vein and causes inflammation and pain.
Thrombophlebitis can lead to serious complications such as pulmonary embolism, which is a life-threatening condition where a blood clot travels to the lungs and blocks the blood flow.
Choice A is correct because wearing fitted elastic thromboembolic hose can help compress the veins and improve the blood flow in the legs, reducing the risk of clot formation.
Choice B is correct because drinking 2 to 3 L of fluid per day can help prevent dehydration, which can make the blood thicker and more prone to clotting.
Choice D is correct because elevating your legs above your heart level can help reduce the pressure and swelling in the veins, improving the blood circulation and preventing stasis.
Choice E is correct because smoking can damage the lining of the blood vessels, increase the blood pressure and heart rate, and make the blood more sticky and likely to clot.
Choice C is wrong because crossing your legs when sitting can impair the blood flow in the legs and increase the risk of thrombophlebitis.
It is recommended to avoid prolonged sitting and to move your legs frequently.
Normal ranges for fluid intake are about 2 to 3 L per day for adults, depending on age, weight, activity level and health conditions.
Normal ranges for leg elevation are about 15 to 30 degrees above the heart level.
Correct Answer is C
Explanation
The correct answer is choice C. Tachycardia and hypotension.
These are signs of shock due to severe blood loss and should be reported to the provider immediately.DIC can cause both excessive clotting and bleeding, which can lead to organ damage and death.
Choice A is wrong because petechiae on the chest and abdomen are common manifestations of DIC due to low platelet count and increased fibrin degradation products.
They are not life-threatening by themselves and do not require immediate intervention.
Choice B is wrong because hematuria in the urinary catheter bag is another manifestation of DIC due to bleeding in the urinary tract.
It is not an emergency unless it is accompanied by other signs of shock or renal failure.
Choice D is wrong because oozing of blood from IV site is also a manifestation of DIC due to impaired coagulation.
It can be managed by applying pressure and changing the dressing.
It is not a priority over signs of shock.
Normal ranges for platelet count are 150,000 to 450,000 per microliter of blood, for fibrinogen level are 200 to 400 mg/dL, for prothrombin time are 11 to 13.5 seconds, for partial thromboplastin time are 25 to 35 seconds, and for D-dimer level are less than 0.5 mcg/mL.
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