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

Answer and Explanation

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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Correct Answer is C

Explanation

A. Increasing systolic blood pressure: Carboprost is not indicated for increasing systolic blood pressure. If a client's blood pressure is elevated, it may require monitoring and, if necessary, treatment with antihypertensive medication.
B. Breast engorgement: Carboprost is not used to address breast engorgement. Breast engorgement is typically managed with measures like warm compresses, breastfeeding, and potentially pain relievers or other interventions.
C. Pooling of blood beneath the buttocks: This is a concerning sign of potential postpartum hemorrhage. Carboprost is indicated in situations where there is excessive bleeding or inadequate uterine contractions to help control bleeding and prevent further complications.
D. Bladder distention: Carboprost is not used to address bladder distention. Bladder distention may require measures such as catheterization to empty the bladder andalleviate discomfort.

A. Apply elastic stockings before the client gets out of bed. B. Apply warm, moist packs to the client's lower legs. C. Have the client ambulate as often as possible. D. Administer NSAIDs every 4 to 6 hours.

Correct Answer is C

Explanation

A: Elastic stockings are used to promote venous return and decrease the risk of thrombosis, but they are not the primary preventive measure against thrombophlebitis.

B: Warm, moist packs may provide comfort and reduce localized swelling, but they do not prevent thrombophlebitis and are not a standard preventive measure.

C: Early and frequent ambulation is the most effective way to prevent thrombophlebitis. It enhances blood flow and prevents stasis, which is a major risk factor for the development of thrombophlebitis.

D: NSAIDs can be used to manage pain and inflammation but are not used as a preventive measure for thrombophlebitis in the postpartum setting.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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