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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
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Correct Answer is C
Explanation
Choice A rationale
The fundus should not be soft or to the right of the umbilicus 12 hours postpartum. A soft or displaced fundus could indicate uterine atony or a full bladder, both of which require intervention.
Choice B rationale
The fundus should not be soft or above the umbilicus 12 hours postpartum. This could indicate uterine atony, which could lead to postpartum hemorrhage.
Choice C rationale
The fundus should be firm and at the level of the umbilicus 12 hours postpartum. This indicates that the uterus is contracting properly to prevent excessive bleeding.
Choice D rationale
The fundus should not be to the left of the umbilicus 12 hours postpartum. This could indicate a full bladder, which can displace the uterus and interfere with uterine contractions
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