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 A

Explanation

Choice A rationale
If the fundus is palpable to the right of the midline, it may indicate that the bladder is distended. A full bladder can displace the uterus to one side.
Choice B rationale
Frequent uterine contractions are not typically associated with bladder distention. These contractions are a normal part of the postpartum period as the uterus returns to its pre- pregnancy size.
Choice C rationale
Having less than 2.5 cm of rubra lochia on a perineal pad does not indicate bladder distention. This is a normal finding in the postpartum period.
Choice D rationale
An increased thirst is not typically associated with bladder distention. It is a common symptom in the postpartum period due to fluid shifts and breastfeeding.

A. The posterior fontanel is palpable. B. The lowermost portion of the fetus is at the level of the ischial spines. C. The largest fetal diameter has passed through the pelvic outlet. D. The fetal head is in the left occiput posterior position.

Correct Answer is D

Explanation

Choice A rationale
The palpability of the posterior fontanel is not related to the position of the fetus.
Choice B rationale
The level of the ischial spines refers to the station of the fetus, not its position.
Choice C rationale
The passage of the largest fetal diameter through the pelvic outlet is a stage of labor, not a fetal position.
Choice D rationale
This is the correct answer. The left occiput posterior position refers to the position of the fetal head.

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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 is caring for a client who is 2 hours postpartum following a vaginal birth. Which of the following findings indicates the client’s bladder is distended?

Correct Answer is A

Explanation

A nurse is examining a client who is in active labor and observes that the presenting part is in the left occiput posterior position. What is the clinical interpretation of this finding?

Correct Answer is D

Explanation

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