A nurse is collecting data from a client who is 20 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect?
Positive Homans' sign
Full, firm breasts
Firm fundus at midline
Lochia serosa
The Correct Answer is C
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.
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Related Questions
Correct Answer is C
Explanation
A. Tachypnea (rapid breathing) is not typically an adverse effect of epidural anesthesia.
B. Hypertension (high blood pressure) is not typically an adverse effect of epidural anesthesia.
C. Tachycardia (rapid heart rate) can be an adverse effect of epidural anesthesia, potentially due to a decrease in blood pressure leading to a compensatory increase in heart rate.
D. Fever is not a common adverse effect of epidural anesthesia.
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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