Nokea
Which assessment finding suggests thrombophlebitis in a postpartum client?
- A. These signs and symptoms are indications of pulmonary embolism.
- B. These signs and symptoms do not relate to thrombophlebitis. Dyspnea, tachypnea, and apprehension
- C. Chills, hypotension, and abdominal tenderness
- D. Positive Homan's sign, calf warmth, and pain
Correct Answer: D
Rationale: The correct answer is D because a positive Homan's sign, calf warmth, and pain are classic signs of thrombophlebitis in a postpartum client. A positive Homan's sign indicates pain in the calf upon dorsiflexion of the foot, which can indicate a blood clot in the leg veins. Calf warmth and pain are also indicative of a possible deep vein thrombosis.
Choices A and B are incorrect because they relate to pulmonary embolism, not thrombophlebitis. Choice C describes signs of sepsis or intra-abdominal pathology, not specifically thrombophlebitis.
In summary, the key indicators of thrombophlebitis in a postpartum client are a positive Homan's sign, calf warmth, and pain, making choice D the correct answer.
You may also like to solve these questions
A nurse is talking to the parents of a 3-year-old child about water safety precautions. Which of the following statements made by the parents indicates a need for clarification?
- A. We keep the toilet seat down at all times.
- B. We don't answer the phone during bath time.
- C. We empty all buckets filled with water.
- D. We have our child in swimming lessons.
Correct Answer: D
Rationale: The correct answer is D because enrolling a 3-year-old child in swimming lessons does not necessarily prevent drowning incidents. It is crucial for parents to understand that even with swimming lessons, active supervision around water is essential to prevent accidents. Keeping the toilet seat down (A), avoiding distractions during bath time (B), and emptying buckets filled with water (C) are all important water safety precautions to prevent drowning incidents. Swimming lessons are beneficial, but they should not replace vigilant supervision.
A new mother receives instructions about care of her newborn son's circumcision. Which statement made by the mother indicates that further teaching is needed?
- A. I will call the doctor if my baby's penis starts to bleed.
- B. I should wash off any yellowish mucous on my baby's penis.
- C. I will put vaseline on his penis every time I change his diaper.
- D. I should give my baby a sponge bath for the first week.
Correct Answer: B
Rationale: The correct answer is B. Washing off yellowish mucous is not recommended as it may be a normal part of the healing process after circumcision. The yellowish mucous is likely to be a scab or healing tissue, and washing it off could interfere with the healing process or cause infection. It is essential to let it fall off naturally. Choices A, C, and D are correct because calling the doctor for bleeding, applying vaseline for protection, and giving a sponge bath for hygiene are appropriate post-circumcision care.
In a child diagnosed with Tetralogy of Fallot, which of the following is a compensatory mechanism to decrease venous return to the heart?
- A. Squatting
- B. Clubbing
- C. Shortness of breath
- D. Polycythemia
Correct Answer: A
Rationale: Squatting is a compensatory mechanism that decreases venous return (deoxygenated blood) to the heart. This clinical sign is commonly seen in young children with Tetralogy of Fallot, a type of cyanotic heart disease. Squatting helps reduce the workload on the heart by decreasing the amount of deoxygenated blood returning to it.
A 38 week gestation newborn weighs 4020 grams, is sluggish, and has limp muscle tone. The baby experienced a broken clavicle during delivery. Based on this information, which can the nurse conclude about the baby?
- A. Neonatal abstinence symptoms
- B. Large for gestational age
- C. Congenital cardiac defect
- D. Respiratory depression
Correct Answer: B
Rationale: The correct answer is B: Large for gestational age. A newborn weighing 4020 grams at 38 weeks is considered large for gestational age. The sluggishness and limp muscle tone can be attributed to the baby's size, which can make movement more challenging. The broken clavicle could have occurred during delivery due to the baby's size and the forces involved. Neonatal abstinence symptoms (choice A) typically present with irritability, tremors, and poor feeding, not sluggishness. Congenital cardiac defects (choice C) usually manifest with cyanosis, tachypnea, and poor feeding. Respiratory depression (choice D) is characterized by poor respiratory effort, not sluggishness and limp muscle tone.
A nurse is caring for a 4-year-old client with full-thickness burns. Which of the following nursing actions are essential for the care of this child? (Select all that apply.)
- A. Monitor level of consciousness
- B. Maintain intravenous fluids
- C. Document vital signs
- D. Provide a low-calorie,high carbohydrate diet
Correct Answer: A,B,C
Rationale: Level of consciousness, IV fluids, vital signs, and urinary output are critical in burn management; a high-protein, high-calorie diet is recommended instead of a low-calorie diet.