A nurse is planning care for a patient who is 2 hours postpartum following a cesarean birth. The patient has a history of thromboembolic disease.Which nursing interventions should be included in the plan of care?
Place pillows under the patient’s knees when resting in bed.
Massage the patient’s posterior lower legs.
Apply warm, moist heat to the patient’s lower extremities.
Have the patient ambulate.
The Correct Answer is D
Choice A rationale
Placing pillows under the patient’s knees when resting in bed can actually increase the risk of thromboembolic disease by slowing blood flow and promoting clot formation.
Choice B rationale
Massaging the patient’s posterior lower legs is not recommended, especially if the patient is showing signs of a possible deep vein thrombosis (DVT), as it could dislodge a clot.
Choice C rationale
Applying warm, moist heat to the patient’s lower extremities is not typically recommended as a primary intervention for patients with a history of thromboembolic disease.
Choice D rationale
Having the patient ambulate can help prevent the formation of blood clots by promoting blood circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choiceB. Expressions of excitement.
Choice A rationale:
Eagerness to learn newborn care skills is more characteristic of the “taking-hold” phase, which follows the “taking-in” phase.During the taking-hold phase, the mother becomes more independent and starts to take an active role in caring for her newborn.
Choice B rationale:
Expressions of excitement are typical during the “taking-in” phase. This phase occurs in the first 1-2 days postpartum, where the mother is primarily focused on herself and her birth experience.She may be excited and talkative about the birth process.
Choice C rationale:
Focus on the family unit and its members is more aligned with the “letting-go” phase, which is the final phase of maternal postpartum adjustment.In this phase, the mother starts to integrate the newborn into the family and adjusts to her new role.
Choice D rationale:
Lack of appetite can occur during the “taking-in” phase due to exhaustion and the physical demands of labor, but it is not a defining characteristic of this phase.
Correct Answer is B
Explanation
Choice A rationale
While the anterior fontanel being soft and level is an important observation in a newborn, it is not typically used as part of a gestational age assessment.
Choice B rationale
The presence of plantar creases covering 3 of the sole is a typical finding in a full-term newborn and is used as part of a gestational age assessment.
Choice C rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is a common finding in newborns, especially shortly after birth. However, it is not typically used as part of a gestational age assessment.
Choice D rationale
Vernix caseosa in the inguinal creases can be a sign of a preterm newborn, as vernix caseosa is typically present in larger amounts in preterm newborns. However, it is not typically used as part of a gestational age assessment.
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