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 C
Explanation
Choice A is incorrect because security tags are a vital part of hospital security protocols to prevent newborn abduction, and they should be worn at all times, even when the baby is in the room with the parent.
Choice B is incorrect as while it is important to have a list of authorized individuals, it does not directly prevent abduction; the staff still needs to verify each person's identity before allowing them to take the baby.
Choice C is correct because it demonstrates the client's understanding that all hospital staff should have proper identification, especially when they are involved in newborn care, which is a critical security measure.
Choice D is incorrect because having only one identification band is insufficient; multiple forms of identification for both the parent and the newborn are necessary to ensure the baby's safety and prevent any mix-up or abduction.
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