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 D
Explanation
Choice A rationale
The "taking-in" phase, lasting the first 24-48 hours postpartum, is characterized by the mother's focus on her own needs (rest, food, fluid), often passively relying on others and reliving the birth experience. The statement about accepting the outcome and focusing on health indicates a move beyond this initial self-focus and is not the primary reflection.
Choice B rationale
The "taking-hold" phase, typically starting 2-3 days postpartum and lasting several weeks, involves the mother assuming responsibility for infant care and focusing on regaining control over her body and mothering skills. The client's statement focuses on the emotional resolution of the birth experience rather than the active mastery of mothering tasks.
Choice C rationale
The term "working-through" is not a formally recognized phase in the classic maternal adjustment theories (Rubin/Mercer). While emotional processing is necessary, the term doesn't accurately describe the specific developmental stage of letting go of the idealized birth plan and accepting the reality.
Choice D rationale
The "letting-go" phase, which is the final stage of maternal adjustment, involves the mother mourning the loss of the idealized or fantasized birth experience (e.g., natural childbirth) and accepting the reality of the birth and her new parental role. The client's statement of "glad that she and her baby are healthy" after hoping for a different birth perfectly reflects this cognitive and emotional resolution and acceptance.
Correct Answer is A
Explanation
Choice A rationale
A second-degree perineal laceration involves the vaginal mucosa, perineal skin, and the perineal muscles, but not the anal sphincter. The proximity of the repair to the urethra and the potential for perineal edema and pain can inhibit the voiding reflex and cause urethral spasm, leading to temporary difficulty in spontaneously emptying the bladder post-delivery.
Choice B rationale
The onset of milk production (lactogenesis II) is primarily controlled by the rapid drop in progesterone levels following the expulsion of the placenta and subsequent increase in prolactin release. A second-degree perineal laceration and repair, which is a localized soft tissue injury, has no direct physiological impact on the endocrine cascade responsible for initiating lactation.
Choice C rationale
Maladaptive bonding is a complex psychological issue influenced by factors like maternal mental health, pain, fatigue, and social support. While a painful laceration can contribute to discomfort and stress, a second-degree tear itself is a physical injury and does not directly cause an abnormal bonding process, which is a behavioral and emotional phenomenon.
Choice D rationale
Posterior vaginal varicosities (enlarged veins) are caused by the increased venous pressure and blood volume associated with pregnancy, and potential pressure from the descending fetal head during labor. A second-degree perineal laceration and its repair are the result of the birthing process and do not cause pre-existing vascular conditions like varicosities.
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