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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Soft and non-tender breasts are a normal finding in the early postpartum period.
B. A urine output of 3,000 mL in 12 hours is within the normal range.
C. A fundus palpable at the umbilicus may be normal within the first few hours after childbirth.
D. A heart rate of 128/min may indicate a postpartum complication, such as hemorrhage or infection, and requires further assessment.

A. The baby should be carried in the parent’s arms from the room to the nursery B. The mom should request that a second staff member verify the identity of any questionable person C. Because of infant security systems, the baby can be left unattended in the client’s room D. Parents should be told it is safe to posting photographs of their infant on the Internet

Correct Answer is B

Explanation

A. Carrying the baby in the parent's arms enhances security but does not directly address the prevention of abduction.
B. Verifying the identity of any questionable person by a second staff member is a key measure to prevent infant abduction.
C. Leaving the baby unattended in the client's room is not a safe practice and does not contribute to preventing abduction.
D. Posting photographs of the infant on the Internet can compromise the child's security and is not recommended.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Correct Answer is D

Explanation

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Correct Answer is B

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