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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Request the RN perform a cervical examination is incorrect, as this action is not indicated for a client who has a history of genital herpes. A cervical examination can introduce infection and trauma to the cervix and increase the risk of viral shedding and transmission to the fetus. The nurse should avoid performing or requesting a cervical examination unless absolutely necessary.

Choice B reason: Initiate fetal monitoring for baseline and changes is correct, as this action is appropriate for any client who is in labor. Fetal monitoring can provide information about the fetal heart rate, variability, accelerations, decelerations, and contractions. The nurse should monitor the fetal status continuously and report any abnormal findings to the provider.

Choice C reason: Prepare for a vaginal birth is incorrect, as this action may not be possible for a client who has a history of genital herpes. A vaginal birth can expose the fetus to the herpes virus and cause neonatal infection, which can be life-threatening. The nurse should assess the client for signs of active lesions or prodromal symptoms and prepare for a cesarean birth if indicated.

Choice D reason: Administer antibiotics is incorrect, as this action is not eﬀective for a client who has a history of genital herpes. Genital herpes is caused by a virus, not a bacteria, and antibiotics have no eﬀect on viral infections. The nurse should administer antiviral medications as prescribed to reduce viral shedding and transmission to the fetus.

A. Feel for a full bladder. B. Check the client's fundus. C. Measure the client's vital signs. D. Request the provider perform a vaginal examination.

Correct Answer is B

Explanation

Choice A reason:
Feeling for a full bladder is not the first action the nurse should take, although it is important to assess for bladder distension and urinary retention in postpartum clients. A full bladder can displace the uterus and increase the risk of uterine atony and hemorrhage.

Choice B reason:
Checking the client's fundus is the first action the nurse should take, as it can indicate the tone and position of the uterus. A firm and midline fundus indicates adequate uterine contraction and prevents excessive bleeding. A boggy or deviated fundus indicates uterine atony or retained placental fragments, which can cause hemorrhage.

Choice C reason:
Measuring the client's vital signs is not the first action the nurse should take, although it is important to monitor for signs of shock and infection in postpartum clients. Vital signs can be aﬀected by various factors and do not provide a direct assessment of uterine status.

Choice D reason:
Requesting the provider perform a vaginal examination is not the first action the nurse should take, as it can introduce infection and trauma to the perineum. A vaginal examination is only indicated if there is suspicion of cervical or vaginal lacerations or retained placenta.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of a client who is at 39 weeks of gestation and has a history of genital herpes. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hours ago. The nurse should identify that which of the following findings places the client at risk for a postpartum hemorrhage?

A nurse is assisting with the care of a client who had an epidural anesthesia block during the early stages of labor. The client's blood pressure is 80/40 mm Hg and the fetal heart recording is 140/min. Which of the following actions should the nurse take first?

A nurse is assisting in the care of a client who is in active labor. The nurse notes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take first?

A nurse is assisting in the care of a client who is in the second stage of labor. Which of the following findings should the nurse report to the provider?

A nurse is collecting data from a client who is 12 hr postpartum following a spontaneous vaginal delivery. The nurse should expect to find the uterine fundus at which of the following positions on the client's abdomen?

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