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. The suprapubic area is typically where the uterus can be palpated, but it's not the location for auscultating fetal heart tones at 12 weeks of gestation.
B. The umbilical area is not the optimal location at this stage; the fetal heart tones are generally not audible in this location until the uterus rises higher into the abdomen in later gestation.
C. At 12 weeks of gestation, the fetal heart tones are typically auscultated above the left iliac crest.
D. Below the liver border on the right abdomen is also not correct, as the fetal heart tones are unlikely to be found there at 12 weeks.
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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