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.
Nursing Test Bank
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Related Questions
Correct Answer is D
Explanation
A. Elevating a baby's head on a cushion during sleep is not recommended, as it may increase the risk of Sudden Infant Death Syndrome (SIDS).
B. Using baby powder with each diaper change is not recommended, as it can be harmful if inhaled by the baby.
C. Setting the hot water heater to 130 degrees Fahrenheit is too hot and can scald a baby. The recommended temperature is around 120 degrees Fahrenheit.
D. This statement indicates an understanding of the importance of regularly changing smoke detector batteries, which is a critical aspect of newborn safety.
Correct Answer is B
Explanation
A. There is no fasting requirement for a nonstress test.
B. The client will press a button whenever they feel the baby move during the test to help correlate fetal movement with changes in the fetal heart rate.
C. A nonstress test is not meant to stimulate contractions. It monitors the fetal heart rate in response to the baby's movements.
D. While the client will be monitored, they are not required to lie flat on their back for the entire duration of the test. They may be in a semi-reclining or comfortable position.
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