The nurse caring for the postpartum client who has developed thrombophlebitis is providing instructions in the management of this condition. Which client statement indicates the need for further instruction?
“I will wear my elastic stockings as prescribed.”.
“I will massage my affected leg regularly.”.
“I will avoid prolonged sitting.”.
“I will elevate my leg if it is swollen.”.
“I will elevate my leg if it is swollen.”.
The Correct Answer is B
Choice A rationale
Elastic stockings help improve venous return, reducing clot propagation in thrombophlebitis. Proper usage minimizes symptoms like pain and swelling, and supports overall vein health, crucial for recovery and preventing complications.
Choice B rationale
Massaging an affected leg with thrombophlebitis is contraindicated as it increases the risk of clot dislodgement, potentially leading to a life-threatening pulmonary embolism. This misconception highlights the need for further client education.
Choice C rationale
Avoiding prolonged sitting prevents venous stasis and encourages circulation, which is vital in thrombophlebitis management to prevent worsening of clotting and associated complications such as pain or swelling.
Choice D rationale
Elevating the affected leg reduces swelling and promotes venous drainage, alleviating discomfort associated with thrombophlebitis. This intervention supports the resolution of inflammation in the superficial veins.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
While lithotomy positioning can increase pressure on perineal tissues, it does not directly correlate with an elevated risk of postpartum hemorrhage. Other factors have stronger evidence for causing hemorrhage.
Choice B rationale
Uterine massage is a preventative measure against postpartum hemorrhage. It stimulates uterine contractions, promoting tone, and reducing atony, which is a primary cause of excessive postpartum bleeding.
Choice C rationale
A third stage lasting less than 10 minutes is within normal limits, reducing the likelihood of placental retention and subsequent bleeding. Prolonged stages, rather than shortened ones, increase risk.
Choice D rationale
Macrosomia, defined as infant birth weight over 4000 grams, increases uterine atony risk due to overdistension, impairing effective contractions post-delivery. Overdistension complicates placental separation, raising postpartum hemorrhage risk.
Correct Answer is D
Explanation
Choice A rationale
Gastric problems later in life are not an immediate concern for infants with myelomeningocele, as they often arise secondary to neurological impairments or medications but do not pose immediate life-threatening risks at birth.
Choice B rationale
Respiratory depression in infants with myelomeningocele is rare unless coexisting brainstem anomalies or complications from anesthesia are present, which are typically managed during medical interventions.
Choice C rationale
Decreased cardiac output is not a primary risk in infants with myelomeningocele unless there is a coexisting cardiac anomaly, which is not a routine feature of this congenital condition.
Choice D rationale
Infection is a critical immediate risk due to the open neural tube defect in myelomeningocele, which exposes the spinal cord and meninges to environmental pathogens, increasing the risk of meningitis or systemic infection.
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