The postpartum nurse is caring for a client 8 hours after an uncomplicated cesarean birth. Which of the following interventions should the nurse include in the client's plan of care to reduce the risk of thrombus formation? Select all that apply.

Question

Quizplus · Accepted Answer

Deep venous thrombosis (DVT) describes the formation of a thrombus (blood clot) that impedes blood flow in a deep vein and may progress to life-threatening pulmonary embolism (PE). Thrombus formation is associated with venous stasis (blood pooling), which may occur during or after surgery due to immobility. In addition, blood hypercoagulability, a physiologic adaptation during pregnancy, also increases the risk of postpartum thrombus formation. The nurse should emphasize interventions that promote blood flow and venous return, especially for clients recovering from cesarean birth. Interventions to prevent postpartum thrombus formation include: Promoting early and frequent ambulation by ensuring adequate pain control (eg, administer analgesic 30 min before activity) (Option A) Instructing the client to perform leg exercises (eg, dorsiflexion, plantar flexion) hourly (Option C) Maintaining prescribed sequential compression devices during sedentary activities (Option D) (Option B) The nurse should have clients ambulate (with assistance) as soon as possible after surgery (ie, usually on the first postoperative day) if they are in stable condition and can support themselves while standing. (Option E) Anticoagulant therapy with heparin, not aspirin, is indicated for postpartum DVT/PE prevention in clients with additional risk factors (eg, history of DVT). Educational objective: Deep venous thrombosis describes the formation of a thrombus that impedes blood flow in a deep vein and may progress to life-threatening pulmonary embolism. Interventions to prevent postpartum thrombus formation include promoting early ambulation by ensuring adequate pain control, instructing the client to perform leg exercises, and maintaining sequential compression devices on the lower extremities.

The Postpartum Nurse Is Caring for a Client 8 Hours