A postpartum client is being treated with subcutaneous heparin for deep vein thrombosis of the left calf.
Which client assessment is of most concern to the nurse?
Presence of varicose veins.
Dyspnea when breastfeeding.
Pulse of 92 beats/min.
Blood pressure of 136/88 mm Hg.
The Correct Answer is B
Choice A rationale
The presence of varicose veins (dilated, tortuous superficial veins) is a common finding during pregnancy due to increased venous pressure and is a risk factor for deep vein thrombosis (DVT). While it warrants monitoring for local signs of inflammation or pain, it is a chronic condition and not an acute sign of a severe complication like a pulmonary embolism (PE).
Choice B rationale
Dyspnea (difficulty breathing) is an acute and concerning symptom, especially in a client with a recent deep vein thrombosis (DVT), as it is a cardinal sign of a pulmonary embolism (PE). A PE occurs when a clot, often originating in the leg, embolizes and obstructs the pulmonary vasculature. This is a life-threatening complication that requires immediate intervention.
Choice C rationale
A pulse of 92 beats/min is slightly elevated but often an expected physiologic response in the postpartum period due to cardiovascular readjustment or mild pain/stress. While tachycardia can be a sign of a pulmonary embolism, a rate of 92 is not severe enough on its own to be the most concerning finding compared to acute respiratory distress (dyspnea). The normal adult pulse rate is 60 to 100 beats/min.
Choice D rationale
A blood pressure of 136/88 mm Hg is considered elevated (prehypertensive or stage 1 hypertension) but is not immediately life-threatening. While it requires follow-up, it is less acutely concerning than dyspnea, which suggests a severe respiratory or circulatory compromise like a pulmonary embolism. The client is not currently in a hypertensive crisis (e.g., ≥ 180/120 mm Hg).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["100"]
Explanation
Step 1 is: Calculate the volume of the magnesium sulfate solution that contains the ordered dose. 500 mL÷30 g = 16.666. mL/g. 6 g/hr×16.666. mL/g = 100 mL/hr. The final calculated answer is 100 mL/hr.
Correct Answer is C
Explanation
Choice A rationale
Preparing for an immediate cesarean birth is not the initial priority; assessment is needed first to confirm the diagnosis, determine the degree of placental involvement, and evaluate maternal-fetal status. A cesarean birth is indicated only if bleeding is heavy or the fetus is distressed, not automatically upon admission.
Choice B rationale
A vaginal examination is strictly contraindicated as a priority action when painless, bright red vaginal bleeding occurs late in the second trimester, as this is the classic sign of placenta previa. Such an examination could cause a catastrophic hemorrhage by disturbing the placental site.
Choice C rationale
An ultrasound assessment is the priority to non-invasively confirm the diagnosis of placenta previa, determine the precise placental location relative to the cervical os, and assess fetal well-being, including estimated weight and amniotic fluid volume. This diagnostic step guides all subsequent safe management decisions.
Choice D rationale
Assessment of uterine contractions using an Intrauterine Pressure Catheter (IUPC) is an invasive procedure requiring ruptured membranes, which is not indicated upon admission for suspected placenta previa. External tocodynamometry is used for contraction monitoring, and the IUPC is reserved for specific labor management situations.
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