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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. I will reduce my exercise schedule to 3 days a week. B. I should limit my carbohydrates to 50% of caloric intake. C. I will take my glyburide daily with breakfast. D. I know I am at increased risk to develop type 2 diabetes.

Correct Answer is A

Explanation

Choice A rationale

Regular physical activity is an important part of managing gestational diabetes. Most guidelines recommend at least 30 minutes of moderate-intensity exercise on most days of the week. Reducing the exercise schedule to only 3 days a week may not provide enough activity to help regulate blood glucose levels.
Choice B rationale
Limiting carbohydrates to 50% of caloric intake can be a part of a balanced diet for managing gestational diabetes. Carbohydrates have the biggest effect on blood sugar levels, so monitoring and regulating carbohydrate intake is key.
Choice C rationale
Glyburide is an oral medication that can be used to manage gestational diabetes when diet and exercise are not enough. It helps to lower blood glucose levels by stimulating the pancreas to release more insulin.
Choice D rationale
It is true that women who have had gestational diabetes are at an increased risk of developing type 2 diabetes later in life. Therefore, this statement does not indicate a need for further teaching.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What action should a nurse take when caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad, with the fundus midline and firm at the umbilicus?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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