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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 A

Explanation

A.

Rationale:

A. Lentils are a legume known for their high fiber content, making them an excellent choice for increasing dietary fiber.

B. While cabbage is a vegetable, it does not contain as much fiber per cup as lentils.

C. Asparagus is a vegetable that contains fiber, but it typically has lower fiber content per cup compared to lentils.

D. Oatmeal is a grain that contains fiber, but lentils generally have a higher fiber content per cup than oatmeal.

Correct Answer is C

Explanation

Rationale:

A. This question addresses pelvic pressure, which may not directly relate to the effectiveness of the hands-and-knees position for occipitoposterior fetal positioning.

B. The spacing of contractions is not typically affected by maternal positioning and therefore is not the most appropriate question to evaluate the effectiveness of this intervention.

C. Asking about improvement in back labor is pertinent because the hands-and-knees position can help alleviate back pain associated with occipitoposterior fetal positioning.

D. Suprapubic pain is not typically associated with occipitoposterior fetal positioning, so this question may not provide useful information regarding the effectiveness of the intervention.

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