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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 B

Explanation

Rationale:

A. Gestational diabetes mellitus is not a contraindication for a contraction stress test. In fact, clients with gestational diabetes may require additional fetal monitoring due to the increased risk of fetal complications.

B. A previous classical incision, also known as a vertical uterine incision, increases the risk of uterine rupture during labor, making a contraction stress test contraindicated.

C. A previous stillbirth is not a contraindication for a contraction stress test. In fact, it may prompt additional fetal monitoring to assess for potential complications in subsequent pregnancies.

D. A nonreactive nonstress test may indicate the need for further evaluation with a contraction stress test; it is not a contraindication in itself.

Correct Answer is ["A","C","D"]

Explanation

Rationale:

A. Vacuum-assisted delivery increases the risk of postpartum hemorrhage due to potential trauma to the birth canal and uterus.

B. A history of human papillomavirus is not directly associated with an increased risk of postpartum hemorrhage.

C. A history of uterine atony (inability of the uterus to contract effectively after delivery) is a significant risk factor for postpartum hemorrhage.

D. Labor induction with oxytocin can lead to uterine hyperstimulation or tetanic contractions, which may contribute to uterine atony and postpartum hemorrhage.

E. Newborn weight is not a risk factor for postpartum hemorrhage.

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