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 B
Explanation
A. There is no fasting requirement for a nonstress test.
B. The client will press a button whenever they feel the baby move during the test to help correlate fetal movement with changes in the fetal heart rate.
C. A nonstress test is not meant to stimulate contractions. It monitors the fetal heart rate in response to the baby's movements.
D. While the client will be monitored, they are not required to lie flat on their back for the entire duration of the test. They may be in a semi-reclining or comfortable position.
Correct Answer is C
Explanation
Choice A is incorrect because security tags are a vital part of hospital security protocols to prevent newborn abduction, and they should be worn at all times, even when the baby is in the room with the parent.
Choice B is incorrect as while it is important to have a list of authorized individuals, it does not directly prevent abduction; the staff still needs to verify each person's identity before allowing them to take the baby.
Choice C is correct because it demonstrates the client's understanding that all hospital staff should have proper identification, especially when they are involved in newborn care, which is a critical security measure.
Choice D is incorrect because having only one identification band is insufficient; multiple forms of identification for both the parent and the newborn are necessary to ensure the baby's safety and prevent any mix-up or abduction.
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