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 A
Explanation
A. At 12 weeks of gestation, the nurse should expect to find the fetal heart tones in the suprapubic area. This is where the uterus is located at this early stage of pregnancy.
B. This is not the correct location for auscultating fetal heart tones at 12 weeks of gestation. The umbilical area is not the typical location for auscultating fetal heart tones at this stage.
C. This is not the correct location for auscultating fetal heart tones at 12 weeks of gestation. At this stage, the nurse should expect to find fetal heart tones in the suprapubic region.
D. This is not the correct location for auscultating fetal heart tones at 12 weeks of gestation. The liver is typically not involved in auscultating fetal heart tones at this stage.
Correct Answer is C
Explanation
A. Expecting docusate sodium to produce a semi-fluid stool within 6 to 12 hours is incorrect. Docusate sodium is a stool softener that usually works within 1 to 3 days, not as quickly as 6 to 12 hours.
B. Decreasing the intake of high-fiber foods while taking docusate sodium is not advised. In fact, maintaining a high-fiber diet is essential for managing constipation effectively.
C. Taking docusate sodium with a full 8-ounce glass of water is correct. Adequate fluid intake is necessary to help the stool soften and facilitate bowel movements when using this medication.
D. Avoiding citrus fruits while taking docusate sodium is not necessary. Citrus fruits can be beneficial as part of a high-fiber diet to help alleviate constipation.
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