A nurse is reinforcing teaching with a newly licensed nurse concerning a client on a postpartum unit following a cesarean birth. Which of the following measures should the nurse include in the instructions to prevent thrombophlebitis?

Apply elastic stockings before the client gets out of bed.

Apply warm, moist packs to the client's lower legs.

Have the client ambulate as often as possible.

Administer NSAIDs every 4 to 6 hours.

Answer and Explanation

The Correct Answer is C

A: Elastic stockings are used to promote venous return and decrease the risk of thrombosis, but they are not the primary preventive measure against thrombophlebitis.

B: Warm, moist packs may provide comfort and reduce localized swelling, but they do not prevent thrombophlebitis and are not a standard preventive measure.

C: Early and frequent ambulation is the most effective way to prevent thrombophlebitis. It enhances blood flow and prevents stasis, which is a major risk factor for the development of thrombophlebitis.

D: NSAIDs can be used to manage pain and inflammation but are not used as a preventive measure for thrombophlebitis in the postpartum setting.

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Correct Answer is B

Explanation

A: The baby should take in both the areola and nipple for effective breastfeeding, not just the nipple.
B: This position helps ensure that the baby's mouth is at the same level as the breast, which promotes proper latch and feeding.
C: The duration of breastfeeding can vary, and it's often recommended to nurse until the baby is satisfied rather than setting a specific time limit.
D: Applying vitamin E oil after each feeding is not a standard practice and is not necessary for successful breastfeeding.

A. A newborn who has blue hands and feet with an axillary temperature of 36.6°C (97.9°F) B. A newborn who has lost 12% of her birth weight C. A newborn who is 24 hr post-circumcision and has yellow exudate D. A newborn who has a blood glucose level of 63 mg/dL

Correct Answer is A

Explanation

A. The newborn with blue hands and feet (acrocyanosis) along with a normal axillary temperature of 36.6°C (97.9°F) could indicate a need for further assessment. While acrocyanosis can be normal in newborns, it is essential to monitor for any signs of respiratory distress or circulatory issues. Since this newborn is exhibiting a potential sign of compromised circulation, this infant should be attended to first.

B. A newborn who has lost 12% of her birth weight is concerning, as significant weight loss in newborns can indicate feeding problems or other underlying issues. However, this would not take precedence over potential acute issues like those indicated in option A.

C. A newborn who is 24 hours post-circumcision with yellow exudate is expected to have some discharge as part of the healing process. If the exudate is not foul-smelling and there are no signs of infection, this is typically a normal finding.

D. A newborn with a blood glucose level of 63 mg/dL is within the normal range for newborns, as acceptable levels are typically above 40 mg/dL. Therefore, this does not require immediate attention.

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A nurse is reinforcing teaching with a newly licensed nurse concerning a client on a postpartum unit following a cesarean birth. Which of the following measures should the nurse include in the instructions to prevent thrombophlebitis?

Nursing Test Bank

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Correct Answer is A

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