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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Step 1: The nurse should observe the lochia during palpation of the fundus. This can help assess the amount and type of vaginal discharge after childbirth.
Step 2: The nurse should not massage a firm fundus. If the uterus is firm, it means it is contracting well to control bleeding.
Step 3: The nurse should determine whether the fundus is midline. A uterus that is not midline may indicate a full bladder, which can interfere with uterine contraction and lead to increased bleeding.
Step 4: Documenting fundal height is not typically done postpartum. Instead, the nurse assesses whether the fundus is firm and midline.
Step 5: The nurse should administer methylergonovine maleate if the uterus is boggy. This medication helps the uterus contract to control bleeding.
Correct Answer is A
Explanation
Choice A rationale
Early decelerations in the fetal heart rate (FHR) are caused by compression of the fetus’s head during a uterine contraction. This often happens during later stages of labor as the baby is descending through the birth canal. They may also occur during early labor if the baby is premature or in a breech position. This causes the uterus to squeeze the head during contractions.
Choice B rationale
Uteroplacental insufficiency is a condition where the placenta does not provide enough oxygen and nutrients to the fetus. This condition is typically associated with late decelerations in the FHR, not early decelerations.
Choice C rationale
Altered fetal cerebral blood flow is not typically associated with early decelerations in the FHR34.
Choice D rationale
Umbilical cord compression is typically associated with variable decelerations in the FHR, not early decelerations.
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