Nokea
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?
- A. Have the client ambulate as often as possible.
- B. Apply warm, moist packs to the client's lower legs.
- C. Apply elastic stockings before the client gets out of bed.
- D. Administer NSAIDs every 4 to 6 hours.
Correct Answer: A
Rationale: Encouraging ambulation stimulates circulation, preventing blood clots and reducing thrombophlebitis risk post-cesarean.
You may also like to solve these questions
A nurse is reinforcing teaching about travel with a client who is pregnant.
Which of the following instructions should the nurse include?
- A. Take a break and walk at least once every hour.
- B. Wear the shoulder harness snug across your shoulder.
- C. Position the lap belt across your hips.
- D. Move your car seat forward, close to the steering wheel.
Correct Answer: A
Rationale: Taking breaks and walking hourly during travel improves circulation, reducing the risk of blood clots, a key concern during pregnancy.
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?
- A. Have the client ambulate as often as possible.
- B. Apply warm, moist packs to the client's lower legs.
- C. Apply elastic stockings before the client gets out of bed.
- D. Administer NSAIDs every 6 to 8 hours.
Correct Answer: A
Rationale: Early ambulation prevents blood stasis, a key measure to reduce thrombophlebitis risk post-cesarean.
A nurse in an antepartum unit is assisting with the care of a client who has preeclampsia and is receiving IV magnesium sulfate therapy.
For which of the following adverse effects should the nurse monitor and report to the provider?
- A. Tachypnea.
- B. Hyporeflexia.
- C. Agitation.
- D. Polyuria.
Correct Answer: B
Rationale: Hyporeflexia indicates magnesium sulfate toxicity, a serious adverse effect requiring immediate reporting to prevent respiratory or cardiac issues.
A nurse is caring for a 2-day-old newborn who is undergoing phototherapy for treatment of hyperbilirubinemia.
Which of the following actions should the nurse take?
- A. Provide additional hydration by offering glucose water.
- B. Apply a water-based lotion to the newborn's skin every 4 hours.
- C. Remove the newborn from phototherapy every 2 hours for breastfeeding.
- D. Monitor the newborn's heart rate every 2 hours.
Correct Answer: C
Rationale: Removing the newborn for breastfeeding every 2 hours ensures nutrition and bonding without significantly disrupting phototherapy.
A nurse is reinforcing teaching with a client about laboratory testing during pregnancy.
Which of the following statements should the nurse include in the teaching?
- A. A multiple marker screening will be performed to identify neural tube defects.
- B. A glucose tolerance test will be performed to predict hyperglycemia in your baby.
- C. A Papanicolaou test will be performed to detect the presence of herpes simplex type 1.
- D. A group B streptococcus screening will be performed to determine the presence of STIs.
Correct Answer: A
Rationale: A multiple marker screening detects neural tube defects and chromosomal abnormalities, typically performed between 15-20 weeks of gestation.