A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis

Vital Signs

Blood Pressure 130/72 mm Hg

Heart rate 90/min

Respiratory rate 18/min

Temperature 37" C (98.6" F)

The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?

For each finding dick to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or an indication that the client's condition is worsening

Leukocytosis

Redness in the extremity

Scant lochia rubra

Increased warmth in the extremity

Tachycardia

Decreased extremity edema

Answer and Explanation

The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"B"}}

Leukocytosis: Indication of Worsening Condition - Leukocytosis, an increase in white blood cell count, may indicate an exacerbation of the deep vein thrombosis or the development of an infection.

Redness in the extremity: Indication of Worsening Condition - Redness in the extremity suggests inflammation or worsening of the deep vein thrombosis.

Scant lochia rubra: Indication of Improving Condition - Scant lochia rubra indicates a decrease in postpartum bleeding, which is a positive sign.

Increased warmth in the extremity: Indication of Worsening Condition - Increased warmth in the extremity suggests increased inflammation and may indicate progression of the deep vein thrombosis.

Tachycardia: Indication of Worsening Condition - Tachycardia, an elevated heart rate, can be a sign of worsening condition, possibly due to complications such as pulmonary embolism.

Decreased extremity edema: Indication of Improving Condition - Decreased extremity edema suggests reduced swelling, which is a positive sign indicating improvement in circulation and reduction of fluid accumulation in the affected limb.

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Correct Answer is C

Explanation

A. While an autopsy can be an option for determining the cause of stillbirth, it is not a requirement, and the decision should be made by the parents. This statement may add undue pressure on the client.

B. There is no legal requirement for parents to name a stillborn fetus. This can be a sensitive topic, and it is essential to respect the parents' wishes and feelings in this regard.

C. Providing the client with photos of the fetus can help the parents in their grieving process, allowing them to create memories and acknowledge their loss. This action can offer emotional support and validation of their experience.

D. Limiting the time the fetus is in the client's room may not consider the parents' need for closure and the opportunity to say goodbye. Encouraging the family to spend time with their stillborn child can be an important aspect of the grieving process.

A. Assist the client in pulling their knees toward their abdomen. B. Apply pressure to the client's fundus. C. Press firmly on the client's suprapubic area. D. Move the client onto their hands and knees.

Correct Answer is A

Explanation

Rationale:

A. The McRoberts maneuver involves flexing the mother's thighs onto her abdomen to straighten the pelvis and allow for easier passage of the baby's shoulder. This action helps to widen the pelvic outlet and facilitate delivery.

B. Applying pressure to the client's fundus is not part of the McRoberts maneuver. Fundal pressure may be used in other techniques to manage shoulder dystocia, such as the Rubin maneuver or Woods' screw maneuver.

C. Pressing firmly on the client's suprapubic area is not part of the McRoberts maneuver. This action may be performed in conjunction with other maneuvers to help dislodge the impacted shoulder.

D. Moving the client onto their hands and knees is not part of the McRoberts maneuver. This position, known as the Gaskin maneuver, may be used as an alternative maneuver to alleviate shoulder dystocia by changing the orientation of the pelvis.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include?

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