A nurse is monitoring a client who had a cesarean delivery for signs of thromboembolism.
Which of the following findings should alert the nurse to this complication?
Shortness of breath and chest pain
Nausea and vomiting
Headache and blurred vision
Fever and chills.
The Correct Answer is A
The correct answer is choice A. Shortness of breath and chest pain are signs of pulmonary embolism (PE), which is a life-threatening complication of deep vein thrombosis (DVT). DVT is a type of blood clot that can occur in the legs or arms, especially during pregnancy and postpartum. PE happens when a blood clot breaks off and travels to the lungs, blocking blood flow.
Choice B is wrong because nausea and vomiting are not specific signs of thromboembolism.
They can be caused by many other conditions, such as morning sickness, food poisoning, or medication side effects.
Choice C is wrong because headache and blurred vision are not typical signs of thromboembolism.
They can be associated with other pregnancy complications, such as preeclampsia or eclampsia.
Choice D is wrong because fever and chills are not common signs of thromboembolism.
They can indicate an infection or inflammation, such as mastitis or endometritis.
Pregnant women have a higher risk of developing DVT and PE because of hormonal changes, increased blood clotting factors, reduced blood flow to the legs, and other factors. The risk is even higher after a cesarean delivery.
Therefore, it is important to know the signs and symptoms of thromboembolism and seek immediate medical attention if they occur. Thromboembolism can be prevented and treated with anticoagulant medications, compression stockings, and physical activity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A) Administering prophylactic antibiotics as ordered.According to the WHO guidelines for the prevention of surgical site infection (SSI), prophylactic antibiotics should be given within 60 minutes before skin incision and discontinued within 24 hours after surgery.
This reduces the risk of SSI by preventing bacterial colonization of the surgical site.
Choice B) Encouraging coughing and deep breathing exercises is wrong because this intervention is mainly for preventing respiratory complications, not SSI.Coughing and deep breathing exercises help to clear secretions and prevent atelectasis and pneumonia.
Choice C) Providing adequate pain control is wrong because this intervention is mainly for improving patient comfort and recovery, not SSI.Pain control may reduce stress and inflammation, but it does not directly affect the risk of SSI.
Choice D) Assessing for signs of deep vein thrombosis (DVT) is wrong because this intervention is mainly for preventing venous thromboembolism (VTE), not SSI.
DVT is a condition where a blood clot forms in a deep vein, usually in the legs.
It can cause pain, swelling, and redness.If the clot breaks off and travels to the lungs, it can cause a pulmonary embolism (PE), which can be life-threatening.
Some other intraoperative interventions for preventing SSI include using an alcohol-based skin prep, maintaining body temperature, using impervious wound protectors, and performing SSI surveillance.
Correct Answer is ["A","B","C","D"]
Explanation
The correct answer is choices A, B, C and D. The type of anesthesia used, the estimated blood loss during surgery, the vital signs and oxygen saturation, and the allergies and medications given are all important information to be included in the hand-off report from the anesthesia provider to the recovery area staff.
These information help to assess the patient’s condition, monitor for complications, and plan for appropriate interventions.
Choice E is wrong because the Apgar scores of the newborn are not relevant to the patient’s recovery from cesarean delivery.
The Apgar scores are used to evaluate the newborn’s physical condition at birth and are usually reported by the neonatal team.
The recovery area staff should focus on the patient’s postoperative care and pain management.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today