A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?

Request a prescription for PRN aspirin from the provider.

Massage the injection site thoroughly following administration.

Instruct the client that they cannot breastfeed while receiving heparin.

Administer the injection in the client's abdomen.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Requesting a prescription for PRN aspirin is incorrect because aspirin is an antiplatelet agent and should not be combined with heparin without specific medical advice due to the increased risk of bleeding.

Choice B reason:

Massaging the injection site is not recommended as it can cause trauma to the tissue and increase the risk of bleeding, which is especially concerning in a patient with deep-vein thrombosis.

Choice C reason:

Instructing the client that they cannot breastfeed while receiving heparin is incorrect. Heparin does not pass into breast milk in significant amounts and is considered safe for use while breastfeeding.

Choice D reason:

Administer the injection in the client's abdomen. Heparin is typically administered subcutaneously in the abdomen to ensure proper absorption and minimize discomfort. Because it is an area with large amounts of subcutaneous fat

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Correct Answer is A

Explanation

The correct answer is A. Apply an ice pack to the affected area. Ice packs are recommended during the first 24 hours after birth to decrease swelling and help with pain.

Choice A reason: Applying an ice pack to the episiotomy site helps reduce swelling and provides pain relief. This is the standard care within the first 24 hours postpartum.

Choice B reason: A warm sitz bath is generally recommended after the first 24 hours following birth. It is not the best immediate action for unrelieved pain shortly after delivery.

Choice C reason: While maintaining cleanliness with a squeeze bottle of antiseptic solution is important for preventing infection, it does not provide the immediate pain relief needed for unrelieved episiotomy pain.

Choice D reason: Heat application, such as placing a hot pack, is not advised within the first 24 hours postpartum because it can increase the risk of swelling and bleeding.

A. Premature ovarian failure. B. Renal calculi. C. Dysmenorrhea. D. Recurrent urinary tract infections.

Correct Answer is A

Explanation

Choice A rationale:

Premature ovarian failure affects the ovaries and leads to early menopause, resulting in the loss of the woman's reproductive ability. This condition can cause infertility due to the depletion or dysfunction of eggs in the ovaries, hindering conception.

Choice B rationale:

Renal calculi (kidney stones) do not directly impact fertility. It is a condition unrelated to the reproductive system.

Choice C rationale:

Dysmenorrhea refers to painful menstruation and, while it can be uncomfortable, it does not necessarily affect fertility.

Choice D rationale:

Recurrent urinary tract infections may be a concern for overall health but do not necessarily directly impact fertility unless there are severe complications. They are unrelated to infertility assessment.

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A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is A

Explanation

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