A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis. How should the nurse interpret the findings 24 hr later?
Decreased extremity edema
Redness in the extremity
Leukocytosis
Tachycardia .
The Correct Answer is A
Choice A rationale
Decreased extremity edema is a positive sign in a client with deep vein thrombosis (DVT) 48 hours postpartum. DVT is a blood clot that forms in a vein deep in the body, often in the lower leg or thigh. Edema, or swelling, is a common symptom. A decrease in edema may indicate that the condition is improving.
Choice B rationale
Redness in the extremity is not a positive sign in a client with DVT1112. Redness can indicate inflammation or infection, which could suggest a worsening of the condition.
Choice C rationale
Leukocytosis, or an increase in the number of white blood cells, is not a positive sign in a client with DVT1112. It can indicate an infection or inflammation, which could suggest a worsening of the condition.
Choice D rationale
Tachycardia, or a fast heart rate, is not a positive sign in a client with DVT1112. It can indicate a response to decreased oxygen levels in the blood, which could suggest a worsening of the condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Frequent urination is a common symptom in early pregnancy due to increased blood flow to the woman’s kidneys. While it can be inconvenient, it is usually not a sign of a serious problem.
Choice B rationale
Periodic tingling of the fingers can be a symptom of carpal tunnel syndrome, which is common during pregnancy due to fluid retention causing pressure on the median nerve. While it can be uncomfortable, it is usually not a serious concern.
Choice C rationale
Back pain following intercourse can be a normal symptom of pregnancy due to hormonal changes and stretching of ligaments. It is usually not a cause for immediate concern.
Choice D rationale
Severe vomiting in early pregnancy could be a sign of hyperemesis gravidarum, a severe form of nausea and vomiting in pregnancy that can lead to dehydration and weight loss. This is a potentially serious condition that requires immediate medical attention.
Correct Answer is A
Explanation
Choice A rationale
Providing the client with a cool sitz bath can help soothe the perineal area, reduce inflammation, and promote healing after a fourth-degree laceration.
Choice B rationale
Administering methylergonovine IM is typically used for the prevention and treatment of postpartum or post-abortion hemorrhage caused by uterine atony or subinvolution. It would not directly address the care of a fourth-degree perineal laceration.
Choice C rationale
Applying a moist, warm compress to the perineum can provide some relief from discomfort, but a cool compress or sitz bath is typically recommended initially after a perineal laceration to help reduce swelling.
Choice D rationale
Applying povidone-iodine to the client’s perineum after she voids is not typically part of the care for a fourth-degree perineal laceration. The area should be kept clean, but routine application of antiseptics is not usually necessary.
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