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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Expressing dissatisfaction with the baby's appearance may indicate a lack of immediate bonding.
B. Noting physical features shared with the father suggests recognition and connection.
C. Declining a baby bath demonstration doesn't necessarily indicate a lack of attachment.
D. Requesting nursery care for sleep doesn't necessarily indicate a lack of attachment.
Correct Answer is C
Explanation
A. Uterine tetany and overproduction of oxytocin are not typically associated with subinvolution.
B. Multiple gestation and postpartum hemorrhage may contribute to uterine atony but not necessarily subinvolution.
C. The most common causes of subinvolution are retained placental fragments and infection.
D. Postpartum hemorrhage may contribute to uterine atony but is not a direct cause of subinvolution.
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