If a woman is at risk for thrombus and is not ready to ambulate, nurses might intervene by doing all of these interventions except:
Notifying the physician immediately if a positive Homan's sign occurs or if warmth, redness, and tenderness of the calf are present.
Having her sit in a chair.
Having her flex, extend, and rotate her feet, ankles, and legs.
Putting her in antiembolic stockings (TED hose) and/or sequential compression device (SCD) boots.
The Correct Answer is B
Choice A rationale
A positive Homan's sign, or warmth, redness, and tenderness of the calf, can be an indicator of deep vein thrombosis (DVT). The nurse should immediately notify the physician if any of these symptoms occur, as early detection and treatment are crucial to prevent a pulmonary embolism.
Choice B rationale
A woman at risk for thrombus should not be encouraged to sit in a chair for prolonged periods. Sitting with legs in a dependent position can cause venous stasis, where blood pools in the lower extremities, increasing the risk of thrombus formation. Ambulation and leg exercises are preferred.
Choice C rationale
Having the woman flex, extend, and rotate her feet, ankles, and legs stimulates muscle contractions in the lower extremities. This action helps to promote venous return and prevent venous stasis, which is a major contributing factor to thrombus formation.
Choice D rationale
Applying antiembolic stockings (TED hose) and/or sequential compression device (SCD) boots helps to improve venous return from the lower extremities to the heart. This mechanical compression prevents blood from pooling in the veins, thereby significantly reducing the risk of thrombus formation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A three-month follow-up visit is not the standard of care for an uncomplicated postpartum recovery. The typical recommendation for the first postpartum check-up is much earlier. The three-month timeframe would be too late to address common postpartum issues, such as lochia, uterine involution, perineal healing, or potential signs of postpartum depression, which need to be assessed and managed earlier.
Choice B rationale
The standard of care for a woman who has had an uncomplicated spontaneous vaginal delivery is to have her first postpartum follow-up visit with her OBGYN at six weeks postpartum. By this time, the uterus should have returned to its pre-pregnancy size and position, lochia should have ceased, and perineal healing should be complete. This visit is crucial for assessing physical recovery, discussing contraception, and screening for postpartum depression.
Choice C rationale
A one-week follow-up visit is typically too early for a routine postpartum check for a patient with an uncomplicated recovery. This timeframe is usually reserved for patients with complications, such as postpartum hemorrhage, infection, or preeclampsia, who require closer monitoring. For a healthy woman, waiting one week is not necessary to assess her recovery progress, as most significant changes occur over a longer period.
Choice D rationale
A two-week follow-up visit is earlier than the standard of care for an uncomplicated postpartum recovery. While some providers may see patients at this time, it is not the universally accepted first follow-up. The six-week visit is considered the benchmark because it allows for adequate time for the body to complete the major physiological changes of the puerperium, ensuring a comprehensive assessment of the patient’s physical and mental health. *.
Correct Answer is A
Explanation
Choice A rationale
A puerperal infection is a bacterial infection occurring after childbirth. A key diagnostic criterion is a temperature of 38° C (100.4° F) or higher, with the fever occurring on two separate occasions during the first 10 days postpartum, excluding the first 24 hours. The temperature elevation is a primary systemic sign of an underlying inflammatory or infectious process, often originating from the reproductive tract.
Choice B rationale
Profuse vaginal bleeding with ambulation, also known as secondary postpartum hemorrhage, can be a symptom of a subinvolution of the uterus, which can be caused by a retained placental fragment or a uterine infection. However, this is not one of the first and most specific signs of puerperal infection. A fever is a more definitive initial indicator.
Choice C rationale
Pain when passing stool is a common postpartum complaint related to perineal trauma, hemorrhoids, or a tear from childbirth. While it can be uncomfortable, it is not a direct symptom of a puerperal infection, which typically manifests with fever, malaise, abdominal pain, and foul-smelling lochia.
Choice D rationale
Fatigue is a universal and expected symptom for all new mothers, especially in the first week postpartum, due to the physical and emotional demands of childbirth and newborn care. It is a non-specific symptom and is not considered a primary indicator for a puerperal infection
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