A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis
Vital Signs
- Blood Pressure 130/72 mm Hg
- Heart rate 90/min
- Respiratory rate 18/min
- Temperature 37" C (98.6" F)
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
For each finding dick to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or an indication that the client's condition is worsening
Leukocytosis
Redness in the extremity
Scant lochia rubra
Increased warmth in the extremity
Tachycardia
Decreased extremity edema
The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"B"}}
Leukocytosis: Indication of Worsening Condition - Leukocytosis, an increase in white blood cell count, may indicate an exacerbation of the deep vein thrombosis or the development of an infection.
Redness in the extremity: Indication of Worsening Condition - Redness in the extremity suggests inflammation or worsening of the deep vein thrombosis.
Scant lochia rubra: Indication of Improving Condition - Scant lochia rubra indicates a decrease in postpartum bleeding, which is a positive sign.
Increased warmth in the extremity: Indication of Worsening Condition - Increased warmth in the extremity suggests increased inflammation and may indicate progression of the deep vein thrombosis.
Tachycardia: Indication of Worsening Condition - Tachycardia, an elevated heart rate, can be a sign of worsening condition, possibly due to complications such as pulmonary embolism.
Decreased extremity edema: Indication of Improving Condition - Decreased extremity edema suggests reduced swelling, which is a positive sign indicating improvement in circulation and reduction of fluid accumulation in the affected limb.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
Rationale:
A. Maternal cytomegalovirus can be transmitted to the newborn through contact with infected bodily fluids, including saliva and urine.
B. Airborne precautions are not necessary for cytomegalovirus, as it is primarily transmitted through contact with infected bodily fluids, not through airborne droplets.
C. There is no prophylactic treatment with acyclovir for cytomegalovirus; treatment options are limited and typically reserved for severe cases.
D. Lesions are not typically visible on the mother's genitalia with cytomegalovirus; the virus is often asymptomatic or causes mild symptoms in healthy adults.
Correct Answer is B
Explanation
Rationale:
A. "Your provider will schedule a chorionic villus sampling to determine the sex of your baby." Chorionic villus sampling (CVS) is a different prenatal test that involves taking a sample of chorionic villi for genetic testing, not determining the sex of the fetus.
B. "This procedure determines if your baby has genetic or congenital disorders."
Correct answer.
Amniocentesis is a prenatal test used to diagnose genetic disorders or chromosomal abnormalities, not to determine the sex of the fetus.
C. "We can schedule the procedure for later today if you'd like." Amniocentesis is not typically scheduled on the same day as requested. It requires prior preparation and scheduling.
D. "You cannot have an amniocentesis until you are at least 35 years of age." There's no age restriction for amniocentesis based solely on maternal age. It's typically recommended for women at higher risk for genetic conditions, regardless of age.
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