A nurse is collecting data from a client who is 20 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect?
Positive Homans' sign
Full, firm breasts
Firm fundus at midline
Lochia serosa
The Correct Answer is C
A. Homans' sign is a test for deep vein thrombosis and is not a normal postpartum finding.
B. Full, firm breasts typically occur a few days after delivery when milk production begins, not at 20 hours postpartum.
C. A firm fundus at the midline is an expected finding in the immediate postpartum period, indicating that the uterus is contracting and involuting properly.
D. Lochia serosa (pinkish-brown discharge) is a normal finding around 3 to 10 days postpartum, but it is not typically present at 20 hours postpartum.
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Related Questions
Correct Answer is C
Explanation
A: Elastic stockings are used to promote venous return and decrease the risk of thrombosis, but they are not the primary preventive measure against thrombophlebitis.
B: Warm, moist packs may provide comfort and reduce localized swelling, but they do not prevent thrombophlebitis and are not a standard preventive measure.
C: Early and frequent ambulation is the most effective way to prevent thrombophlebitis. It enhances blood flow and prevents stasis, which is a major risk factor for the development of thrombophlebitis.
D: NSAIDs can be used to manage pain and inflammation but are not used as a preventive measure for thrombophlebitis in the postpartum setting.
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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