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 B
Explanation
Choice A rationale
Encouraging the client to perform Kegel exercises can help strengthen pelvic floor muscles, but it does not address the immediate problem of a displaced and boggy uterus.
Choice B rationale
Assisting the client to the bathroom to void is the correct action. A full bladder can displace the uterus and prevent it from contracting properly, which can lead to uterine atony and increased risk of postpartum hemorrhage.
Choice C rationale
Asking the client to rate her pain is important, but it does not address the immediate problem of a displaced and boggy uterus.
Choice D rationale
Encouraging the client to move to the left lateral position can improve venous return and cardiac output, but it does not address the immediate problem of a displaced and boggy uterus
Correct Answer is B
Explanation
To calculate the estimated date of birth (EDB) using the first day of the last menstrual period (LMP), you can use Naegele’s Rule. This rule adds 280 days (or 40 weeks) to the first day of the LMP.
Given the LMP of July 27 (0727):
- Add 1 year: July 27, 2023 becomes July 27, 2024.
- Add 7 days: July 27, 2024 becomes August 3, 2024.
- Subtract 3 months: August 3, 2024 becomes May 3, 2024.
So, the estimated date of birth (EDB) is May 3, 2024 (0503).
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