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 C
Explanation
A. Homans' sign is a test for deep vein thrombosis and is not a normal postpartum finding.
B. Full, firm breasts typically occur a few days after delivery when milk production begins, not at 20 hours postpartum.
C. A firm fundus at the midline is an expected finding in the immediate postpartum period, indicating that the uterus is contracting and involuting properly.
D. Lochia serosa (pinkish-brown discharge) is a normal finding around 3 to 10 days postpartum, but it is not typically present at 20 hours postpartum.
Correct Answer is C
Explanation
A. Placing the client in a side-lying position may be a comfort measure, but it may not address the afterpains directly.
B. Applying a cool compress may provide some relief, but it may not be as effective as administering medication for pain relief.
C. Administering ibuprofen or other appropriate pain medication can help relieve afterpains, which are caused by uterine contractions after childbirth.
D. Encouraging Kegel exercises is not relevant to relieving afterpains. Kegel exercises are beneficial for pelvic floor muscle strength but do not directly address afterpains.
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