A nurse is reinforcing teaching with a newly licensed nurse concerning a client on a postpartum unit following a cesarean birth. Which of the following measures should the nurse include in the instructions to prevent thrombophlebitis?

Apply elastic stockings before the client gets out of bed.

Apply warm, moist packs to the client's lower legs.

Have the client ambulate as often as possible.

Administer NSAIDs every 4 to 6 hours.

Answer and Explanation

The Correct Answer is C

A: Elastic stockings are used to promote venous return and decrease the risk of thrombosis, but they are not the primary preventive measure against thrombophlebitis.

B: Warm, moist packs may provide comfort and reduce localized swelling, but they do not prevent thrombophlebitis and are not a standard preventive measure.

C: Early and frequent ambulation is the most effective way to prevent thrombophlebitis. It enhances blood flow and prevents stasis, which is a major risk factor for the development of thrombophlebitis.

D: NSAIDs can be used to manage pain and inflammation but are not used as a preventive measure for thrombophlebitis in the postpartum setting.

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Correct Answer is C

Explanation

A: This infection does not directly cause hearing loss at birth. Hearing loss in newborns can be associated with genetic factors, birth complications, and certain infections, but GBS is not known to be a direct cause of hearing impairment.

B: A positive GBS test result does not necessitate a cesarean birth. The standard management for GBS-positive mothers is the administration of intrapartum antibiotic prophylaxis, not cesarean delivery, unless there are other obstetric indications.

C: Testing for GBS is typically done between 36 and 37 weeks of gestation because this timing is close to delivery, when the test results are most predictive of the baby's risk of exposure during birth.

D: Antibiotics are not given during the last 2 weeks of pregnancy to prevent GBS transmission. Instead, they are administered during labor to ensure effective levels of the drug during delivery, which is the critical period for preventing transmission to the baby.

A. Apply an antiseptic to the newborn's heel after collecting the specimen. B. Warm the newborn's heel for 5 to 10 min before the puncture. C. Use a lancet to puncture the inner aspect of the newborn's heel. D. Leave the newborn's heel open to the air after the puncture.

Correct Answer is B

Explanation

A. Applying an antiseptic after the puncture can be done to prevent infection, but it is not the initial step.
B. Warming the newborn's heel helps to increase blood flow, making the collection process more effective and less painful.
C. The puncture should be made on the outer aspect of the newborn's heel, where there is a good blood supply.
D. After the puncture, it is important to apply pressure to the site to stop bleeding, typically using a gauze pad or cotton ball.

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A nurse is reinforcing teaching with a newly licensed nurse concerning a client on a postpartum unit following a cesarean birth. Which of the following measures should the nurse include in the instructions to prevent thrombophlebitis?

Nursing Test Bank

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