A nurse is teaching the parent of a newborn who underwent a circumcision using the Gomco method.
Which of the following statements by the parent indicates an understanding of the teaching?

Choice A rationale

Severe preeclampsia is characterized by high blood pressure, often accompanied by seizures (eclampsia). The client is at high risk for seizures, which can cause falls and injury. Ensuring the side rails are up is a critical safety measure to protect the client from falling out of bed during a seizure episode. This precaution is part of seizure protocols and is essential for client safety in this high-risk condition.

Choice B rationale

Ambulation is contraindicated for clients with severe preeclampsia. They are at high risk for seizures and should be on strict bed rest to minimize physical activity and stress, which can elevate blood pressure and increase the risk of a seizure. Bed rest also helps to improve placental perfusion, which is often compromised in preeclampsia.

Choice C rationale

In a client with severe preeclampsia, fetal well-being is a major concern. The client should have continuous or frequent fetal monitoring, not just twice daily. The compromised placental perfusion can lead to fetal distress, and frequent monitoring, such as nonstress tests or biophysical profiles, is necessary to detect any signs of distress and intervene promptly.

Choice D rationale

A low-protein diet is not recommended for a client with severe preeclampsia. Preeclampsia often causes proteinuria, a loss of protein in the urine, which can lead to low serum albumin levels. A high-protein diet is often encouraged to replace the lost protein and maintain oncotic pressure, which helps to reduce edema.

Choice A rationale

Measuring the client's legs with a tape measure is the correct action to ensure proper sizing of the antiembolic stockings. Correct sizing is critical for effective venous compression and to prevent complications such as skin irritation, tissue damage, or impaired circulation. Stockings that are too tight can act as a tourniquet, while those that are too loose will not provide the necessary graduated compression to facilitate venous return and prevent blood stasis, which is the underlying cause of deep-vein thrombosis. This precise measurement ensures the stockings fit snugly and provide optimal therapeutic benefit.

Choice B rationale

Removing the stockings every 24 hours is an insufficient interval for skin integrity checks and to allow for proper cleaning and assessment. The standard practice involves removing antiembolic stockings at least twice daily for a short period. This allows the nurse to inspect the client's skin for any signs of pressure, irritation, or breakdown, and to perform hygiene. Prolonged, continuous wear without breaks can compromise skin integrity and increase the risk of developing pressure injuries, especially in a client who is less mobile due to their condition.

Choice C rationale

Folding the stockings at the top is a harmful and dangerous practice. Folding creates a constrictive band around the client's leg, which acts as a tourniquet. This constriction impedes venous and lymphatic return, leading to increased risk of blood stasis, edema, and tissue damage. The pressure from the folded band can severely compromise circulation and potentially worsen the client's underlying deep-vein thrombosis. The stockings should be smooth and wrinkle-free to provide uniform graduated compression.

Choice D rationale

Massaging the legs of a client with deep-vein thrombosis (DVT) is contraindicated and can be extremely dangerous. Massaging can dislodge the thrombus (blood clot) from the venous wall. If the clot becomes dislodged, it can travel through the bloodstream, leading to a pulmonary embolism (PE), a life-threatening condition where the clot obstructs a pulmonary artery in the lungs. Therefore, any form of massage or direct pressure on the affected limb is strictly avoided to prevent this potentially fatal complication. *.