A nurse is planning care for a patient who is 2 hours postpartum following a cesarean birth. The patient has a history of thromboembolic disease.Which nursing interventions should be included in the plan of care?

Place pillows under the patient’s knees when resting in bed.

Massage the patient’s posterior lower legs.

Apply warm, moist heat to the patient’s lower extremities.

Have the patient ambulate.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Placing pillows under the patient’s knees when resting in bed can actually increase the risk of thromboembolic disease by slowing blood flow and promoting clot formation.
Choice B rationale
Massaging the patient’s posterior lower legs is not recommended, especially if the patient is showing signs of a possible deep vein thrombosis (DVT), as it could dislodge a clot.

Choice C rationale
Applying warm, moist heat to the patient’s lower extremities is not typically recommended as a primary intervention for patients with a history of thromboembolic disease.
Choice D rationale
Having the patient ambulate can help prevent the formation of blood clots by promoting blood circulation.

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Correct Answer is D

Explanation

Choice A rationale
The left lower quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice B rationale
The right upper quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice C rationale
The left upper quadrant is not the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.
Choice D rationale
The right lower quadrant is the most likely location to auscultate fetal heart tones if the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on

the client’s right side. These findings suggest that the fetus is in a breech position with its back on the left side, which would place the fetal chest, and thus the heart tones, in the right lower quadrant.

A. “This is a probable sign of pregnancy.”. B. “This is a possible sign of pregnancy.”. C. “This is a presumptive sign of pregnancy.”. D. “This is a positive sign of pregnancy.”.

Correct Answer is C

Explanation

Choice A rationale
A probable sign of pregnancy includes objective signs observed by an examiner, such as changes in the pelvic organs, enlargement of the abdomen, and positive pregnancy test.
Choice B rationale
Possible signs of pregnancy are those that are subjective and reported by the patient, such as nausea, vomiting, and missed period. These signs could be due to other conditions.
Choice C rationale
Feeling the baby moving, also known as quickening, is a presumptive sign of pregnancy. These are changes felt by the woman herself and can be caused by other conditions.
Choice D rationale
Positive signs of pregnancy are those that are confirmed by the examiner and cannot be caused by any other condition. These include hearing the fetal heartbeat, visualizing the fetus, and feeling the baby move.

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A nurse is planning care for a patient who is 2 hours postpartum following a cesarean birth. The patient has a history of thromboembolic disease.Which nursing interventions should be included in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client’s right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

Correct Answer is D

Explanation

A nurse in a prenatal clinic is caring for a client who believes she might be pregnant because she feels the baby moving.Which statement should the nurse make?

Correct Answer is C

Explanation

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