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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Among the options listed, the intrauterine device (IUD) has the lowest failure rate. IUDs are highly effective at preventing pregnancy with a failure rate of less than 1%.
B. Oral contraceptives have a higher failure rate compared to IUDs.
C. The contraceptive sponge has a higher failure rate compared to IUDs.
D. The diaphragm has a higher failure rate compared to IUDs.
Correct Answer is A
Explanation
A. Recurrent variable decelerations of the fetal heart rate (FHR) are concerning and can indicate fetal distress.
B. Uterine contractions every 6 minutes may not provide effective progress in labor, but it is not indicative of fetal distress.
C. Uterine contractions lasting 30 to 45 seconds are within the normal range for labor.
D. Moderate variability of the FHR is a reassuring sign and indicates that the fetus is tolerating labor well.
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