A nurse is collecting data from a client who is 2 days postoperative following a cesarean birth. Which of the following findings should the nurse report to the provider?
Left calf tenderness
Moderate lochia rubra
Urine output of 3,000 mL
Breast engorgement
The Correct Answer is A
A. Left calf tenderness can be a sign of deep vein thrombosis (DVT), which is a serious postoperative complication and should be reported to the provider.
B. Moderate lochia rubra is an expected finding after a cesarean birth.
C. A urine output of 3,000 mL is within normal range and does not warrant immediate reporting to the provider.
D. Breast engorgement is an expected finding in the postpartum period, especially if the client is not breastfeeding. It does not require immediate reporting.
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Related Questions
Correct Answer is D
Explanation
A. Uterine atony
Uterine atony refers to the lack of muscle tone in the uterus after delivery, leading to excessive bleeding. This is not typically associated with abruptio placentae, which involves the premature separation of the placenta from the uterine wall during pregnancy, typically presenting with different symptoms such as painful contractions and bleeding.
B. Polyhydramnios
Polyhydramnios refers to an excessive amount of amniotic fluid during pregnancy and is not a characteristic of abruptio placentae. Polyhydramnios can be associated with various conditions but is not directly linked to placental abruption.
C. Painless vaginal bleeding
Painless vaginal bleeding is more characteristic of placenta previa, a condition where the placenta is abnormally positioned over the cervix. Abruptio placentae, on the other hand, typically presents with painful vaginal bleeding due to the detachment of the placenta from the uterine wall.
D. Board-like abdomen
A board-like abdomen is a classic sign of abruptio placentae, indicating significant uterine muscle contraction and possible internal hemorrhage. The sudden separation of the placenta can cause blood to accumulate behind the placenta, leading to a rigid, "board-like" feeling of the abdomen, which is a hallmark symptom of this condition.
Correct Answer is D
Explanation
A. Nausea is a common side effect of terbutaline, but it is not typically a cause for concern. It may be managed with measures like taking the medication with food.
B. Tremors are a known side effect of terbutaline. While they may be uncomfortable for the client, they are an expected side effect and not necessarily indicative of a problem requiring immediate intervention.
C. Dizziness can occur as a side effect of terbutaline. It is important to monitor the client for this, but it is not typically a severe side effect that requires immediate reporting to the provider.
D. Crackles (also known as rales) in the lungs suggest the possibility of fluid accumulation, which could be a sign of pulmonary edema. This is a serious concern and should be reported to the provider promptly, as it may require a change in treatment or further evaluation.
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