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. Left calf tenderness can be a sign of deep vein thrombosis (DVT), which is a serious postoperative complication and should be reported to the provider.
B. Moderate lochia rubra is an expected finding after a cesarean birth.
C. A urine output of 3,000 mL is within normal range and does not warrant immediate reporting to the provider.
D. Breast engorgement is an expected finding in the postpartum period, especially if the client is not breastfeeding. It does not require immediate reporting.
Correct Answer is D
Explanation
A. Resuming an exercise program within 24 hours after a cervical cerclage placement is not recommended, as it can put unnecessary strain on the cervix.
B. The cerclage is typically removed closer to the end of pregnancy, around 36-38 weeks, not at 10 weeks.
C. While urinary frequency can be a concern during pregnancy, it is not directly related to cervical cerclage placement.
D. Avoiding sexual activity is important after a cervical cerclage placement to reduce the risk of complications and to support the integrity of the cervix.
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