A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis. How should the nurse interpret the findings 24 hr later?
Decreased extremity edema
Redness in the extremity
Leukocytosis
Tachycardia .
The Correct Answer is A
Choice A rationale
Decreased extremity edema is a positive sign in a client with deep vein thrombosis (DVT) 48 hours postpartum. DVT is a blood clot that forms in a vein deep in the body, often in the lower leg or thigh. Edema, or swelling, is a common symptom. A decrease in edema may indicate that the condition is improving.
Choice B rationale
Redness in the extremity is not a positive sign in a client with DVT1112. Redness can indicate inflammation or infection, which could suggest a worsening of the condition.
Choice C rationale
Leukocytosis, or an increase in the number of white blood cells, is not a positive sign in a client with DVT1112. It can indicate an infection or inflammation, which could suggest a worsening of the condition.
Choice D rationale
Tachycardia, or a fast heart rate, is not a positive sign in a client with DVT1112. It can indicate a response to decreased oxygen levels in the blood, which could suggest a worsening of the condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Hematuria, or blood in the urine, is not a normal finding in pregnancy. It could indicate a urinary tract infection, kidney stones, or other kidney problems. However, without more information, it’s not possible to determine the significance of this finding in a client who is at 33 weeks of gestation.
Choice B rationale
A BUN (Blood Urea Nitrogen) level of 40 mg/dL is higher than the normal range, which is between 7 and 20 mg/dL17181920. This could indicate that the kidneys are not working properly. However, it could also be due to a high-protein diet, dehydration, or other factors.
Choice C rationale
Leukorrhea, or vaginal discharge, is a common symptom of pregnancy. It is usually thin, white or clear, and mild smelling. If the discharge is yellow, green, or gray, has a strong smell, or is accompanied by itching or burning, it could indicate an infection.
Choice D rationale
A platelet count of 90,000/mm is lower than the normal range, which is between 150,000 and 450,000/mm25. This could indicate a condition called thrombocytopenia, which can be caused by various conditions, including pregnancy25. However, without more information, it’s not possible to determine the significance of this finding in a client who is at 33 weeks of gestation25.
Correct Answer is B
Explanation
Choice A rationale
A heart rate of 89/min is within the normal range for an adult, and would not typically be a cause for concern.
Choice B rationale
Cool, clammy skin can be a sign of shock or other serious conditions such as hypoperfusion or inadequate blood flow, which could be a sign of hemorrhage or other circulatory issues. This is a significant finding that should be reported to the provider immediately. Hypoperfusion can lead to inadequate oxygen supply to the body’s organs and tissues, which can result in organ failure and other serious complications. Therefore, any signs of hypoperfusion, including cool, clammy skin, should be reported to the provider immediately for further evaluation and treatment.
Choice C rationale
A blood pressure of 120/70 mm Hg is within the normal range for an adult, and would not typically be a cause for concern.
Choice D rationale
Moderate lochia serosa is a normal finding in a woman who is 3 days postpartum. Lochia serosa is the term for the pink or brownish discharge that occurs after lochia rubra, the bright red discharge that occurs immediately after childbirth. Lochia serosa typically begins about 3- 4 days after delivery and can continue for up to 10 days postpartum.
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