Exhibits
The nurse is reviewing the chart.
Select the condition from the choices below to fill in each blank in the following sentence.
Based on the client's history and physical, the nurse notes that this postpartum client is most at risk for developing
The Correct Answer is {"dropdown-group-1":"C"}
Based on the client's history and physical, the nurse notes that this postpartum client is most at risk for developing thromboembolism
Rationale
Prolonged immobility during labor and instrumental delivery are risk factors for venous thromboembolism (VTE) due to stasis of blood flow in the lower extremities. In addition, epidural anesthesia can contribute to venous stasis by impairing mobility and reducing the ability to feel discomfort or urgency to move.
The immediate postpartum period, especially after a prolonged labor and delivery, poses an increased risk of VTE due to hypercoagulability and vascular damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale
A. Respiratory rate is important because opioid-induced respiratory depression is a significant concern with hydromorphone. Assessing the respiratory rate helps the nurse detect early signs of respiratory depression.
B. Pain scale is essential to evaluate the effectiveness of the equianalgesic dose. The nurse should ensure that the pain is adequately controlled with the IV dose comparable to what was achieved with the PO dose.
C. Blood pressure is monitored to detect any potential hypotensive effects of hydromorphone, particularly with IV administration.
D. Level of consciousness is assessed to ensure that the client is not overly sedated or experiencing other neurological side effects of the medication.
Correct Answer is D
Explanation
Rationale
A. The complement system is part of the immune response and can be activated in various conditions, including sepsis. However, activation of complement pathways does not directly cause DIC. Instead, in septic shock, the release of pro-inflammatory cytokines and tissue factor can trigger systemic coagulation activation, leading to DIC.
B. Inhibition of red blood cell production, such as in conditions like aplastic anemia or certain types of bone marrow disorders, does not directly cause DIC. DIC is primarily a disorder of excessive activation of clotting factors in response to underlying conditions like sepsis, trauma, or cancer.
C. Production of extra platelets, or thrombocytosis, is not the cause of DIC. Thrombocytosis can occur in response to various conditions, but DIC involves consumption of platelets due to widespread activation of clotting within the vasculature.
D. DIC is characterized by the widespread consumption and depletion of clotting factors and platelets as they are used up in the formation of microthrombi throughout the bloodstream. This depletion leads to an increased risk of bleeding due to insufficient clotting factors remaining to maintain hemostasis.
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