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.
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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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Assisting the family to identify prior use of positive coping skills in family crises can be helpful, but it’s not the priority action in this situation.
Choice B rationale
Anticipating a prescription by the provider for an antidepressant might be necessary if the client is diagnosed with postpartum depression. However, the nurse first needs to assess the risk to the client and her newborn.
Choice C rationale
Asking the client if she has considered harming her newborn is the priority action. This question is crucial in assessing for postpartum depression and the safety of the newborn.
Choice D rationale
Reinforcing postpartum and newborn care discharge teaching is important, but it’s not the priority action when the client is expressing feelings of sadness and lack of energy.
Correct Answer is C
Explanation
Choice A rationale
Avoiding sexual relations for 3 days is not sufficient advice for a client diagnosed with a sexually transmitted infection (STI). The client should abstain from sexual activity until they and their partner(s) have completed treatment and are symptom-free.
Choice B rationale
Even if a sexual partner has no symptoms, they could still be infected and require treatment. Many STIs can be asymptomatic, meaning they do not show symptoms, but can still be transmitted to others.
Choice C rationale
Returning in 6 months for retesting is a good practice for individuals diagnosed with an STI. Some infections, like chlamydia and gonorrhea, should be retested about 3 months after treatment. Other infections, like HIV, might need a follow-up test 6 months later to confirm the results.
Choice D rationale
The treatment for STIs varies depending on the specific infection. Not all STIs are treated with a single dose of erythromycin. For example, gonorrhea is typically treated with an injection of ceftriaxone and oral azithromycin.
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