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 A

Explanation

Choice A reason: Fundal consistency is correct, as this finding can indicate the eﬀectiveness of oxytocin in stimulating uterine contraction and preventing postpartum hemorrhage. Oxytocin is a uterotonic agent that can enhance or augment uterine contractility and involution. The nurse should monitor the fundal height, consistency, and position and report any signs of uterine atony or excessive bleeding.

Choice B reason: Fetal heart rate is incorrect, as this finding is not relevant for a client who has already delivered the baby. Fetal heart rate can indicate the fetal well-being and response to labor, but it is not aﬀected by oxytocin administration after birth. The nurse should monitor the newborn's vital signs and appearance and report any signs of distress or infection.

Choice C reason: Pulse rate is incorrect, as this finding is not specific for evaluating the eﬀectiveness of oxytocin. Pulse rate can indicate the client's hemodynamic status and response to blood loss, but it can be inﬂuenced by many other factors, such as pain, anxiety, fever, or dehydration. The nurse should monitor the client's vital signs and ﬂuid balance and report any signs of shock or infection.

Choice D reason: Urinary output is incorrect, as this finding is not specific for evaluating the eﬀectiveness of oxytocin. Urinary output can indicate the client's renal function and ﬂuid balance, but it can be inﬂuenced by many other factors, such as ﬂuid intake, bladder distension, or epidural anesthesia. The nurse should monitor the client's intake and output and report any signs of oliguria or retention.

Choice E reason: Blood pressure is incorrect, as this finding is not specific for evaluating the eﬀectiveness of oxytocin. Blood pressure can indicate the client's hemodynamic status and response to blood loss, but it can be inﬂuenced by many other factors, such as pain, anxiety, preeclampsia, or medication. The nurse should monitor the client's vital signs and ﬂuid balance and report any signs of hypotension or hypertension.

A. Check the client's temperature every 4 hr. B. Remind the client to bear down with each contraction. C. Maintain the client in the lithotomy position. D. Encourage the client to empty the bladder every 2 hr.

Correct Answer is D

Explanation

Choice A reason: Check the client's temperature every 4 hr is incorrect, as this action is not frequent enough for a client who had an amniotomy. The nurse should check the client's temperature every 2 hr after an amniotomy, as there is an increased risk of infection due to the rupture of membranes. The nurse should also monitor for signs of chorioamnionitis, such as foul-smelling amniotic ﬂuid, maternal tachycardia, or fetal tachycardia.

Choice B reason: Remind the client to bear down with each contraction is incorrect, as this action is not appropriate for a client who is in the active phase of the first stage of labor. The nurse should instruct the client to avoid bearing down or pushing until they are in the second stage of labor, when the cervix is fully dilated and eﬀaced. Bearing down too early can cause cervical edema, lacerations, or exhaustion.

Choice C reason: Maintain the client in the lithotomy position is incorrect, as this action is not optimal for a client who is in the active phase of the first stage of labor. The lithotomy position is a supine position with the legs elevated and abducted, which can reduce blood ﬂow to the uterus and placenta, increase perineal edema, and limit pelvic outlet diameter. The nurse should encourage the client to change positions frequently and use upright or lateral positions that can enhance uterine contractility, fetal descent, and maternal comfort.

Choice D reason: Encourage the client to empty the bladder every 2 hr is correct, as this action can promote labor progress and prevent bladder distension and infection. The nurse should assist the client to void every 2 hr after an amniotomy, as there may be decreased sensation of bladder fullness due to pressure from the fetal head. A full bladder can interfere with uterine contractions, fetal descent, and cervical dilation.

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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 care of a client who is receiving oxytocin via IV infusion following a vaginal delivery. Which of the following findings should the nurse monitor to evaluate eﬀectiveness of this medication?

Correct Answer is A

Explanation

A nurse is assisting in the care of a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is assisting with the monitoring of a client who is in the first stage of labor, with an external fetal monitor in place and IV ﬂuids infusing. Which of the following factors will cause variable decelerations in the fetal heart rate?

A nurse is collecting data from a client who is 3 days postpartum and is breastfeeding. Her fundus is three fingerbreadths below the umbilicus, and her lochia rubra is moderate. Her breasts feel hard and warm. Which of the following recommendations should the nurse give the client?

A nurse is reinforcing teaching with a client who is in labor about why epidural anesthesia is not initiated until a good labor patern has been established. Which of the following explanations should the nurse include?

A nurse is reinforcing teaching about signs preceding the onset of labor with a client who is at 39 weeks of gestation. Which of the following statements should the nurse include?

A nurse is reinforcing teaching about reducing the risk of perineal infection with a client who had a vaginal birth. Which of the following information should the nurse include in the teaching? (Select all that apply.)

A nurse is caring for a client who is requesting to go to the bathroom immediately after a vaginal birth. Which of the following actions should the nurse take?

A nurse is assisting with the care of a client who is in labor. The client's labor is difficult and prolonged and she reports a severe backache. Which of the following factors is a contributing cause of difficult, prolonged labor?

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?