A nurse is caring for a client who is 1 day postpartum following a cesarean birth. To prevent thrombophlebitis, the nurse should contribute which of the following interventions to the client's plan of care?
Apply warm, moist soaks to the client's lower legs.
Have the client ambulate frequently in the hallway.
Keep the client on bed rest.
Place pillows under the client's knees while she is resting in bed.
The Correct Answer is B
Choice A reason: Apply warm, moist soaks to the client's lower legs is incorrect, as this action is not effective for preventing thrombophlebitis. Warm, moist soaks can provide comfort and reduce inflammation, but they do not improve blood circulation or prevent clot formation.
Choice B reason: Have the client ambulate frequently in the hallway is correct, as this action can prevent thrombophlebitis by improving venous return and preventing stasis. The nurse should encourage and assist the client to ambulate early and frequently after a cesarean birth, as long as there are no contraindications. The nurse should also monitor the client for signs of orthostatic hypotension and provide support as needed.
Choice C reason: Keep the client on bed rest is incorrect, as this action can increase the risk of thrombophlebitis by reducing blood flow and promoting stasis. Bed rest can also delay wound healing and increase the risk of infection and deconditioning. The nurse should avoid keeping the client on bed rest unless absolutely necessary.
Choice D reason: Place pillows under the client's knees while she is resting in bed is incorrect, as this action can impair blood circulation and increase the risk of thrombophlebitis. Placing pillows under the knees can cause pressure on the popliteal veins and reduce venous return. The nurse should advise the client to avoid crossing their legs or placing pillows under their knees while resting in bed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D reason:
Placing the client in a knee-chest or Trendelenburg position is the first action the nurse should take, as it can relieve pressure on the cord and prevent compression and fetal hypoxia. The nurse should also use a sterile gloved hand to hold the presenting part off the cord.
Choice A reason:
Preparing the client for an emergency cesarean birth is an important action, as it can facilitate prompt delivery and prevent fetal compromise. However, this is not the first action the nurse should take, as it does not address the immediate problem of cord prolapse.
Choice B reason:
Covering the cord with a sterile, moist saline dressing is an important action, as it can prevent drying and infection of the cord. However, this is not the first action the nurse should take, as it does not address the immediate problem of cord compression.
Choice C reason:
Explaining to the client what is happening is an important action, as it can provide emotional support and education for the client. However, this is not the first action the nurse should take, as it does not address the immediate problem of cord prolapse.
Correct Answer is ["B","C","E"]
Explanation
Choice A reason: Administer terbutaline if the fundus is boggy is incorrect, as this action is contraindicated for a client who has a boggy fundus. Terbutaline is a tocolytic agent that can relax uterine contractions and worsen uterine atony and hemorrhage. The nurse should administer oxytocin or other uterotonic agents as prescribed to stimulate uterine contraction and prevent bleeding.
Choice B reason: Observe the lochia during palpation of fundus is correct, as this action can provide information about the amount, color, consistency, and odor of lochia. Lochia is the vaginal discharge that occurs after birth, which consists of blood, mucus, and tissue. The nurse should observe the lochia during fundal palpation and report any abnormal findings, such as excessive bleeding, large clots, foul smell, or infection.
Choice C reason: Document fundal height is correct, as this action can provide information about the progress of uterine involution. The fundus is the upper part of the uterus that can be palpated through the abdomen after birth. The nurse should document the fundal height in relation to the umbilicus and note any changes over time.
Choice D reason: Massage a firm fundus is incorrect, as this action is not necessary for a client who has a firm fundus. A firm fundus indicates adequate uterine contraction and involution and prevents excessive bleeding. The nurse should massage a boggy or soft fundus until it becomes firm and midline.
Choice E reason: Determine whether the fundus is midline is correct, as this action can provide information about the position of the uterus and bladder. The fundus should be midline and not displaced to either side. A deviated fundus can indicate bladder distension, which can interfere with uterine contraction and involution and increase the risk of hemorrhage and infection. The nurse should assist the client to empty their bladder and reassess the fundal position.
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