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. Vernix caseosa is a white, cheese-like substance covering the baby's skin.
B. Erythema toxicum neonatorum is a benign rash that appears in the early days of life.
C. Harlequin sign is a transient color change in a newborn, not related to blue hands and feet.
D. Acrocyanosis is a common and temporary condition where the hands and feet may appear blue due to poor peripheral circulation. It is not typically a sign of coldness.

A. At the level of the umbilicus B. 2 cm above the umbilicus C. One fingerbreadth above the symphysis pubis D. To the right of the umbilicus

Correct Answer is A

Explanation

A. The uterine fundus is expected to be at the level of the umbilicus after delivery and descends approximately one fingerbreadth (or 1 cm) per day after delivery.
B. The uterine fundus would be too high for this time frame.
C. The fundus should reach the level of the symphysis pubis by 10 days postpartum.
D. The uterine fundus should not be palpated to the right of the umbilicus; it should be midline or slightly to the right. A lateral displacement of the fundus may indicate a full bladder, which can interfere with uterine contraction and increase the risk of bleeding.

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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 new mother states that her infant must be cold because the baby’s hands and feet are blue. This common and temporary condition is called what?

Correct Answer is D

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A nurse is caring for a client who experienced a vaginal delivery 16 hr ago. When palpating the client’s abdomen, at which of the following positions should the nurse expect to find the uterine fundus?

Correct Answer is A

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