A nurse is collecting data from a client who is 2 days postoperative following a cesarean birth. Which of the following findings should the nurse report to the provider?
Left calf tenderness
Moderate lochia rubra
Urine output of 3,000 mL
Breast engorgement
The Correct Answer is A
A. Left calf tenderness can be a sign of deep vein thrombosis (DVT), which is a serious postoperative complication and should be reported to the provider.
B. Moderate lochia rubra is an expected finding after a cesarean birth.
C. A urine output of 3,000 mL is within normal range and does not warrant immediate reporting to the provider.
D. Breast engorgement is an expected finding in the postpartum period, especially if the client is not breastfeeding. It does not require immediate reporting.
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Related Questions
Correct Answer is D
Explanation
A. Resuming an exercise program within 24 hours after a cervical cerclage placement is not recommended, as it can put unnecessary strain on the cervix.
B. The cerclage is typically removed closer to the end of pregnancy, around 36-38 weeks, not at 10 weeks.
C. While urinary frequency can be a concern during pregnancy, it is not directly related to cervical cerclage placement.
D. Avoiding sexual activity is important after a cervical cerclage placement to reduce the risk of complications and to support the integrity of the cervix.
Correct Answer is D
Explanation
A. Upper abdominal pain could indicate a variety of issues, including gastrointestinal upset or muscle soreness from labor, but it is not specific to a puerperal infection.
B. Bradycardia (slow heart rate) is not typically associated with a puerperal infection.
C. Hypothermia (low body temperature) is not a typical sign of a puerperal infection.
D. Foul-smelling lochia can be indicative of an infection, as an unpleasant odor may be associated with bacterial growth in the uterine cavity. This is a concerning sign and should be further evaluated.
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