NCO Clotting
Which statement made by a new nurse would indicate to the nurse mentor that additional teaching is needed regarding emergency treatment procedures for the local complication of intravenous therapy involving thrombosis? Select all that apply. One, some, or all responses may be correct."I should lower the extremity of the client.""I should apply warm compresses to stabilize the clot.""I should apply cold compresses to decrease the blood flow.""I should use low-dose thrombolytic agent that can lyse the clot.""I should stop the infusion but keep the short peripheral catheter in place." Confident
"I should lower the extremity of the client." "I should apply warm compresses to stabilize the clot." I should stop the infusion but keep the short peripheral catheter in place."
The nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? A 59-year-old who had a knee replacement A 60-year-old who has bacterial pneumonia A 68-year-old who had emergency dental surgery A 76-year-old who has a history of thrombocytopenia
A 59-year-old who had a knee replacement Rationale Clients who have had a joint replacement have decreased mobility; they are at risk for developing thrombophlebitis, which may lead to pulmonary embolism if the clot becomes dislodged into the circulation. Bacterial pneumonia and emergency dental surgery are not associated with an increased risk for pulmonary embolism. A history of thrombocytopenia leads to a decreased ability to clot, so it increases the risk of bleeding but decreases the risk of a thrombus or embolus.
Which action would help prevent venous thrombosis in a client during the perioperative period? Select all that apply. One, some, or all responses may be correct. Administer subcutaneous heparin injections. Give intravenous thrombolytic medications. Assist the client to don antiembolism stockings. Apply pneumatic compression devices to the legs. Remind the client about the importance of bed rest.
Administer subcutaneous heparin injections. Assist the client to don antiembolism stockings. Apply pneumatic compression devices to the legs. Rationale Actions that help prevent postoperative venous thrombosis include administration of anticoagulant medications such as heparin, use of anti-embolism stockings, and use of pneumatic compression devices. Thrombolytic medications dissolve clots rather than prevent them and are typically not used for venous thrombosis because of the high bleeding risk associated with their use. Bed rest leads to venous stasis of blood and increases venous thrombosis risk.
Which gauge is best for the pregnant client to use when estimating how heavy the vaginal bleeding is? Number of clots that were passed Changes in fetal activity when bleeding Increased weakness since bleeding began Amount of blood lost in relation to usual menstrual flow
Amount of blood lost in relation to usual menstrual flow That's right! Rationale Determining the amount of blood lost in relation to the usual menstrual flow gives the client a familiar gauge with which to estimate the amount of bleeding the client is experiencing. The presence of clots does not indicate the amount of bleeding. Changes in fetal activity may indicate a problem, but there is no relationship to the amount of bleeding. Weakness is a subjective symptom and may not reflect blood loss.
Which assessment would the nurse include in the plan of care for a postpartum client with large, painful varicose veins? Monitoring daily clotting times Assessing for peripheral pulses Monitoring daily hemoglobin values Assessing for signs of thrombophlebitis
Assessing for signs of thrombophlebitis Rationale Varicose veins predispose the client to thrombophlebitis; warmth, redness, and pain in the calf are signs of thrombophlebitis. The clotting mechanism is not affected; clot formation results because of venous pooling and decreased venous return caused by the impaired vasculature. The problem is venous, not arterial, so pulses are not affected. Hemoglobin values are affected by the amount of bleeding that occurred during the birth, which usually is not severe enough to impair circulatory competency.STUDY TIP: Remember that intelligence plays a vital role in your ability to learn. However, being smart involves more than just intelligence. Being practical and applying common sense are also part of the learning experience.
Which postpartum client is at the highest risk for disseminated intravascular coagulation (DIC)? Gravida III with twins Gravida V with endometriosis Gravida II who had a 9-lb baby Gravida I who has had an intrauterine fetal death
Gravida I who has had an intrauterine fetal death Intrauterine fetal death is one of the risk factors for DIC; other risk factors include abruptio placentae, amniotic fluid embolism, sepsis, and liver disease. Multiple pregnancy, endometriosis, and increased birthweight are not risk factors for DIC.
The nurse is admitting a client to the unit after fetal death was confirmed by ultrasound. While initiating intravenous (IV) therapy, the nurse notes blood continually oozing from the puncture site. Which is the nurse's next action? Restarting the line distal to the initial site Starting the prescribed infusion of oxytocin Informing the primary health care provider of this finding Placing an oxygen mask on the client and setting the flow rate at 8 L/min
Informing the primary health care provider of this finding Oozing from a venipuncture site is a sign that disseminated intravascular coagulopathy (DIC) is developing. This pathological form of clotting causes widespread bleeding and clotting. It is never a primary diagnosis; it always results from some problem that has triggered the clotting cascade. The primary health care provider must be informed immediately, because this diagnosis will change the client's plan of care. There is no information indicating the need for a different IV site. Also, subsequent venipunctures must be proximal and not distal to previous sites. Delivery will likely be managed initially with oxytocin; however, this is not the first action to be taken in regard to an oozing IV site. Generally oxygen is started for signs of hypoxia, fetal or maternal; because there is no fetal indication for oxygen and no information indicating maternal hypoxia, application of oxygen is not the next intervention.
Which type of lochia would the visiting nurse expect to observe on a client's pad on the third day after a vaginal delivery? Scant alba Scant rubra Moderate rubra Moderate serosa
MODERATE RUBRA Rationale The uterus sloughs off the blood, tissue, and mucus of the endometrium postdelivery. This happens in 3 stages that will vary in length and represent the normal healing of the endometrium. Lochia rubra is the first and heaviest stage of lochia. The blood that is expelled during lochia rubra will be bright red and may contain blood clots. The lochia rubra phase typically lasts for about 3 days but may last up to 7 days. Lochia serosa is the second stage of postpartum bleeding and is thinner in consistency and brownish or pink in color. Lochia serosa typically lasts about 2 weeks, although for some women it can last up to 4 to 6 weeks postpartum. Lochia alba is the final stage of lochia; rather than blood, you will see a white or yellowish discharge that is generated during the healing process and the initial reconstruction of the endometrium. Expect this discharge to continue for around 6 weeks after birth, but keep in mind that it may extend beyond that if the second phase of lochia lasted longer than 2 weeks.
After the birth of her child, a mother tells the nurse, "I was told that my baby has to have an injection of vitamin K. Why is this necessary?" Which response by the nurse is appropriate? "Your baby needs the injection to promote development of red blood cells." "An injection of vitamin K will help keep your baby from becoming jaundiced." "Newborns are deficient in vitamin K. This treatment will ensure adequate levels." "A newborn's blood clots extremely rapidly. This injection will help decrease the clotting time."
Newborns are deficient in vitamin K. This treatment will ensure adequate levels." Rationale The absence of intestinal flora in the newborn results in a low level of vitamin K, causing a transient blood coagulation deficiency; for this reason an injection of vitamin K is given prophylactically on the day of birth. Vitamin K has no effect on red blood cell production. Vitamin K is important for the synthesis of the clotting factor in the liver, but it will not prevent jaundice. Newborns have a blood coagulation deficiency; the blood clots more slowly, not more quickly.
For which reason is a postpartum client encouraged to walk? Respirations are enhanced. Bladder tonicity is increased. Abdominal muscles are strengthened. Peripheral vasomotor activity is promoted.
Peripheral vasomotor activity is promoted. So close! Rationale There is extensive activation of the blood-clotting factors after a birth; this, together with immobility, trauma, or sepsis, encourages thromboembolization. Walking promotes vasomotor activity and helps decrease the risk of thromboembolism. Respirations are enhanced by encouraging the client to turn from side to side and deep-breathe and cough. Bladder tone is improved by regular voiding and filling of the bladder. Exercise during the next 6 weeks can strengthen the abdominal muscles.
Which potential complication of severe preeclampsia may result from severe hypertension? Stroke Hemorrhage Precipitous labor Disseminated intravascular coagulation
STROKE Rationale The likelihood of a stroke increases with a rising blood pressure reading. The degree of hypertension is not associated with hemorrhage. The course of labor is not affected by blood pressure changes except in the presence of abruptio placentae. Fluctuations in blood pressure do not affect the status of clotting factors.
A postpartum client receiving a continuous heparin infusion for a deep vein thrombosis has an activated partial thromboplastin time (aPTT) of 128 seconds. Which action would the nurse take in response to this situation? a)Increase the IV rate of heparin. b)Interrupt the infusion and notify the primary health care provider of the aPTT result. C)Document the result on the medical record and recheck the aPTT in 4 hours. d)Call the primary health care provider to obtain a prescription for a low-molecular-weight heparin.
b)Interrupt the infusion and notify the primary health care provider of the aPTT result. Rationale The heparin should be withheld, because 128 seconds is almost 4 times the normal time it takes a fibrin clot to form (25-36 seconds), and prolonged bleeding may result; the therapeutic range for heparin is 1½ to 2 times the normal range. The primary health care provider should be notified. The dosage of heparin must not be increased, because the client already has received too much. Documenting the result on the medical record and rechecking the aPTT in 4 hours is an unsafe option. Continuing the infusion could result in hemorrhage. The medication does not have to be changed; it should be stopped temporarily until the aPTT is within the therapeutic range.
The nurse instructs a multipara who has just given birth to a large-for-gestational-age (LGA) infant how best to maintain a contracted uterus. Which statement indicates that the teaching was effective? "I'll call you if I have a clot larger than the size of a softball." "I'll breastfeed my baby frequently and on demand." "I should be sure to get up and urinate every 6 hours." "I'll call you every 15 minutes to massage my uterus."
breast feeding 2/25/23, 7:35 AMElsevier Adaptive Quizzing - Quiz performance 95/110pregnancy. The expected fasting blood glucose is 70 to 105 mg/dL (3.9-5.8 mmol/L); it begins to rise in the second trimester and peaks in the third trimester. The white blood cell (WBC) count during pregnancy is 5000 to 15,000 mm . It begins to increase in the second trimester and peaks in the third. Which client would the nurse expect to experience the most severe afterbirth pains? Rationale A multipara's uterus tends to contract and relax spasmodically, even if the uterine tone is effective, resulting in pain that may require an analgesic for relief. Although breast-feeding increases the contractile state of the postpartum uterus, the breast-feeding primipara will not have the typical afterbirth pains of a multipara. Primiparas are less likely to have afterbirth pains than multiparas. A cesarean birth has no effect on the development of afterbirth pains. The nurse instructs a multipara who has just given birth to a large-for-gestational-age (LGA) infant how best to maintain a contracted uterus. Which statement indicates that the teaching was effective? Rationale Breastfeeding can help to stimulate intrinsic oxytocin release. Frequent breastfeeding should be encouraged to promote uterine involution, bonding, and milk production. Theuterus must be massagedif the fundus is boggy. Frequent urination should be encouraged at least every 2-3 hours. Stating that she will call every 15 minutes to have her uterus massaged does not actively involve the mother in her own care and could be unsafe if the uterus becomes boggy during the 15-minute intervals. In the immediate postpartum period, the nurse should instruct the client to call if she has any sudden gushes of fluid from the vagina, if she feels saturated, or if she is passing any blood clots.
