A nurse is planning care for a client who is 2 hours postpartum following a cesarean birth. The client has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care?
Place 3 to 4 pillows under the client's knees when resting in bed.
Massage the client's posterior lower legs.
Have the client ambulate.
Apply warm, moist heat to the client's lower extremities.
The Correct Answer is C
A. Placing pillows under the client's knees may provide comfort but does not address the prevention of thromboembolic disease.
B. Massaging the client's posterior lower legs may increase the risk of dislodging a clot in clients with a history of thromboembolic disease.
C. Having the client ambulate helps prevent venous stasis and reduces the risk of thromboembolic events.
D. Applying warm, moist heat to the client's lower extremities may provide comfort but does not address the prevention of thromboembolic disease.
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Related Questions
Correct Answer is B
Explanation
A. Placing an identification bracelet is important but not the immediate priority after ensuring a patent airway.
B. Drying the skin is a priority to prevent heat loss and promote thermoregulation in the newborn.
C. Administering vitamin K is important but can be done after drying the skin.
D. Administering eye prophylaxis is important but can be done after drying the skin.
Correct Answer is C
Explanation
A. Placing pillows under the client's knees may provide comfort but does not address the prevention of thromboembolic disease.
B. Massaging the client's posterior lower legs may increase the risk of dislodging a clot in clients with a history of thromboembolic disease.
C. Having the client ambulate helps prevent venous stasis and reduces the risk of thromboembolic events.
D. Applying warm, moist heat to the client's lower extremities may provide comfort but does not address the prevention of thromboembolic disease.
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