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 D
Explanation
A. Subconjunctival hemorrhage is common in newborns due to birth trauma and usually resolves without intervention. It does not typically require reporting.
B. Rust-stained urine in the first few days of life is caused by uric acid crystals and is considered a normal finding during neonatal adaptation.
C. Transient circumoral cyanosis (bluish discoloration around the mouth) can occur immediately after birth due to immature peripheral circulation and generally resolves quickly with warming and oxygenation.
D. A single palmar crease, especially if present on one hand, can be associated with chromosomal abnormalities such as trisomy 21 (Down syndrome). This finding warrants further evaluation and should be reported to the provider for assessment and potential diagnostic follow-up.
Correct Answer is B
Explanation
Rationale:
A. Polycythemia: Polycythemia, an elevated red blood cell count, is not typically associated with forceps-assisted birth.
B. Facial palsy:
Correct answer. Facial palsy, or weakness or paralysis of facial muscles, can occur as a complication of forceps-assisted birth due to pressure or trauma to the facial nerve during delivery.
C. Bronchopulmonary dysplasia: Bronchopulmonary dysplasia is a lung condition primarily affecting premature infants and is not directly related to the method of delivery.
D. Hypoglycemia: Hypoglycemia, low blood sugar levels, can occur in newborns for various reasons but is not specifically associated with forceps-assisted birth unless there are other complicating factors.
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