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. Keeping the baby's bassinet away from fans and air conditioning is a correct practice to prevent chilling.
B. Checking the baby's temperature rectally every hour is not a standard practice and may lead to unnecessary discomfort for the baby.
C. Keeping the baby's head covered is generally recommended for warmth.
D. Keeping the infant swaddled in a warm blanket is a good practice for maintaining warmth.
Correct Answer is B
Explanation
A. This is not appropriate for the taking-in stage, as the woman may not be ready to absorb new information or focus on self-care. She may need more verbal instruction and demonstration from the nurse.
B. The taking-in stage is a period of passive, dependent behavior in which the woman reviews her childbirth experience and adjusts to the new role of motherhood. She may need to talk about her labor and delivery repeatedly and seek reassurance from others. The nurse should listen attentively and validate her feelings.
C. This is more suitable for the taking-hold stage, which occurs after the taking-in stage. In this stage, the woman becomes more active and independent, and shows interest in learning how to care for herself and her baby.
D. This is also more appropriate for the taking-hold stage, when the woman develops confidence and competence in her maternal role. In the taking-in stage, she may be more focused on her own needs and rely on others to care for the baby.
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