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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

A.

Leukocytosis

B.

Redness in the extremity

C.

Scant lochia rubra

D.

Increased warmth in the extremity

E.

Tachycardia

F.

Decreased extremity edema

Answer and Explanation

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.


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Related Questions

Correct Answer is C

Explanation

Rationale:

A. A WBC count of 11,000/mm3 is slightly elevated but may be within normal limits, as the normal range for WBC count can vary slightly depending on the laboratory. It is not typically concerning during pregnancy.

B. A hematocrit of 37% is within the normal range for pregnancy (37% to 47%) and does not require immediate reporting to the provider.

C. A fasting blood glucose level of 180 mg/dL is significantly elevated and indicates hyperglycemia, which may be indicative of gestational diabetes mellitus or pre-existing diabetes. This finding should be reported to the provider for further evaluation and management.

D. A creatinine level of 0.9 mg/dL is within the normal range (0.5 to 1 mg/dL) and does not require immediate reporting to the provider.

Correct Answer is B

Explanation

Rationale:

A. Vaginal candidiasis would not typically contraindicate the use of a suppository for constipation.

B. A third-degree perineal laceration involves injury to the anal sphincter and rectal mucosa, making the use of a suppository contraindicated due to the risk of exacerbating the injury and causing further discomfort.

C. Abdominal distention may indicate constipation, which could be a reason for using a suppository, rather than a contraindication.

D. Afterpains, or uterine cramping after childbirth, would not typically contraindicate the use of a suppository for constipation.

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