A nurse on the postpartum unit is performing a physical assessment of a client who is being admitted with a suspected deep-vein thrombosis (DVT). Which of the following clinical findings should the nurse anticipate the client will exhibit?

Area of warmth

Report of nausea

Cool-to-touch extremity

Calf tenderness when massaged .

Answer and Explanation

The Correct Answer is D

Choice A rationale
While an area of warmth can be a symptom of deep vein thrombosis (DVT), it is not the most specific or indicative symptom. DVT is a condition in which blood clots form in veins located deep inside the body, usually in the thigh or lower legs. The most common symptoms include swelling of the foot, ankle, or leg, usually on one side, cramping of the affected leg, severe leg pain, and skin on the affected area that is warmer than the skin on surrounding areas.
However, these symptoms can also be associated with other conditions, making them less specific for DVT.
Choice B rationale
Nausea is not typically a symptom of deep vein thrombosis (DVT). The most common symptoms of DVT include swelling of the foot, ankle, or leg, usually on one side, cramping of the affected leg, severe leg pain, and skin on the affected area that is warmer than the skin on surrounding areas.
Choice C rationale
A cool-to-touch extremity is not typically a symptom of deep vein thrombosis (DVT). In fact, the skin over the affected area is often warmer than the skin on surrounding areas. Therefore, a cool-to-touch extremity would not typically be expected in a client with suspected DVT.
Choice D rationale
Calf tenderness when massaged is a common clinical finding in clients with deep vein thrombosis (DVT)2. DVT often causes pain and swelling in the affected leg, and this pain can be particularly noticeable or worsen when the calf is massaged or the client is standing or walking. Therefore, calf tenderness when massaged would be a clinical finding that a nurse should anticipate in a client being admitted with a suspected DVT.

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Correct Answer is A

Explanation

Choice A rationale
Evaluating the firmness of the uterus is the first action the nurse should take when a client’s blood pressure is 60/50 mm Hg after giving birth. A soft or “boggy” uterus can indicate uterine atony, a condition in which the uterus fails to contract after birth. Uterine atony can lead to significant postpartum hemorrhage, which can cause hypotension.
Choice B rationale
Oxygenating by rebreather mask may be necessary if the client shows signs of hypoxia or difficulty breathing, but it is not the first action the nurse should take.
Choice C rationale
Administering oxytocin infusion can stimulate uterine contractions and help control postpartum bleeding. However, the nurse should first assess the firmness of the uterus.
Choice D rationale
Obtaining a type and crossmatch may be necessary if the client needs a blood transfusion, but it is not the first action the nurse should take.

A. White breads and rice B. Meat, poultry, and fish C. Deep red or orange vegetables D. Dark green, leafy vegetables

Correct Answer is D

Explanation

Choice A rationale
White breads and rice are not particularly high in calcium and would not be the best source of calcium for a client who does not like milk.
Choice B rationale
Meat, poultry, and fish can contain some calcium, but they are not the best source of calcium for a client who does not like milk.
Choice C rationale
Deep red or orange vegetables, while nutritious, are not particularly high in calcium.
Choice D rationale
Dark green, leafy vegetables are a good source of calcium. For a client who is in the 8th week of gestation and does not like milk, these vegetables would be a good alternative source of calcium.

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A nurse on the postpartum unit is performing a physical assessment of a client who is being admitted with a suspected deep-vein thrombosis (DVT). Which of the following clinical findings should the nurse anticipate the client will exhibit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client’s blood pressure is 60/50 mm Hg. What is the first action the nurse should take?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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