To prevent thromboembolism following a cesarean birth, which of the following would be the most important intervention to implement?
Encourage the client to ambulate.
Instruct the client to press inward on their abdomen periodically.
Urge the client to cough and take deep breaths.
Urge the client not to dislodge the IV fluid line.
The Correct Answer is A
Choice A rationale
Ambulation is the most effective intervention for preventing thromboembolism. Movement of the lower extremities promotes venous return and blood flow, preventing venous stasis, which is the primary predisposing factor for clot formation. Encouraging the client to get out of bed and walk as soon as medically stable after a cesarean birth reduces the risk of deep vein thrombosis and subsequent pulmonary embolism by a significant margin.
Choice B rationale
Instructing the client to press inward on their abdomen periodically is not an intervention for thromboembolism prevention. This action may cause discomfort and does not promote blood flow in the lower extremities. It is not a scientifically supported method for preventing venous stasis or clot formation in the legs, which are the main concerns for thromboembolism in this population.
Choice C rationale
Urging the client to cough and take deep breaths is an intervention to prevent respiratory complications like atelectasis and pneumonia. While important for post-operative care, this action does not directly address the risk of thromboembolism in the lower extremities. The mechanism of clot formation is related to venous stasis, which is best addressed by movement and not by respiratory exercises.
Choice D rationale
Urging the client not to dislodge the IV fluid line is an important general safety measure to ensure proper hydration and medication administration. However, it is not an intervention specifically aimed at preventing thromboembolism. The risk of thromboembolism is a circulatory issue related to venous stasis, and this action does not impact blood flow or clot formation in the veins. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
This is a significant underestimation of a 2-3 year old's language skills. While a toddler can follow commands, their expressive language is also developing rapidly. They typically transition from single words to multi-word sentences and have a vocabulary of several hundred words. The lack of speech would be a cause for concern and would require further developmental evaluation.
Choice B rationale
This is the expected language skill level for a 2-3 year old toddler. At this stage, a toddler's vocabulary expands significantly, and they begin to combine words into simple sentences. This two-word stage, often called "telegraphic speech," is a key milestone and indicates the child is beginning to understand and apply grammatical rules.
Choice C rationale
This is an overestimation of a 2-3 year old's language skills. While their vocabulary is growing, their speech is not typically fully clear or understandable to all listeners. They may still mispronounce words or omit certain sounds. Full clarity of speech is usually not achieved until 4 or 5 years of age.
Choice D rationale
This is an overestimation of a 2-3 year old's vocabulary. The typical vocabulary for a 2-year-old is around 50 words, and by age 3, it may increase to around 200-300 words. A vocabulary of 800-900 words is more characteristic of a 4 to 5 year old and is not the expected norm for this age group.
Correct Answer is C
Explanation
Choice A rationale
Adjusting the intravenous fluid infusion rate is not the immediate priority after an amniotomy. This action is not directly related to the most critical and immediate potential complication of this procedure, which is a change in the fetal heart rate. The primary concern is the potential for umbilical cord prolapse, which can lead to fetal hypoxia.
Choice B rationale
Providing a clean gown and linens is important for client comfort and hygiene, but it is not the immediate priority. The nurse must first ensure the safety of the fetus by assessing for complications that can arise from the procedure, such as umbilical cord compression or prolapse, which can lead to fetal distress and requires immediate intervention.
Choice C rationale
The immediate priority after an amniotomy is to assess the fetal heart rate. The sudden release of amniotic fluid can cause the umbilical cord to prolapse and become compressed, leading to a rapid decrease in blood flow and oxygen to the fetus. This compression results in fetal bradycardia, a critical finding requiring immediate intervention to prevent fetal hypoxia and death.
Choice D rationale
Assisting the client to wash the perineum is a hygiene measure that can be performed after the immediate safety of the fetus has been established. It is not the priority action. The nurse must first rule out any life-threatening complications to the fetus, such as cord prolapse, which is a significant risk following the rupture of membranes.
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