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. The McRoberts maneuver involves flexing the mother's thighs onto her abdomen to straighten the pelvis and allow for easier passage of the baby's shoulder. This action helps to widen the pelvic outlet and facilitate delivery.
B. Applying pressure to the client's fundus is not part of the McRoberts maneuver. Fundal pressure may be used in other techniques to manage shoulder dystocia, such as the Rubin maneuver or Woods' screw maneuver.
C. Pressing firmly on the client's suprapubic area is not part of the McRoberts maneuver. This action may be performed in conjunction with other maneuvers to help dislodge the impacted shoulder.
D. Moving the client onto their hands and knees is not part of the McRoberts maneuver. This position, known as the Gaskin maneuver, may be used as an alternative maneuver to alleviate shoulder dystocia by changing the orientation of the pelvis.
Correct Answer is B
Explanation
Rationale:
A. Epigastric discomfort is not typically associated with pyelonephritis. It may be a symptom of other conditions such as gastrointestinal issues or preeclampsia.
B. Flank pain is a common manifestation of pyelonephritis, which is an infection of the kidneys.
Clients with pyelonephritis often experience pain in the flank area, which is located between the lower ribs and the pelvis, on one or both sides of the body.
C. A temperature of 37.7°C (99.8°F) may indicate a low-grade fever, which can be present in pyelonephritis due to the body's immune response to infection.
D. Abdominal cramping may occur with various conditions during pregnancy but is not specific to pyelonephritis.
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