Which data collected during your assessment may indicate a ...

[cartlidgeashley]

Which data collected during your assessment may indicate a vaginal wall hematoma?
 
  a. Firm uterus at U-1
  b. Pulse rate of 110 bpm
  c. Moderate lochia
  d. Soreness of perineum

Question 2

If a DVT (deep vein thrombosis) is suspected, the nurse should:
 
  a. perform a Homans sign on the affected leg.
  b. dorsiflex the foot of the affected leg.
  c. palpate the affected leg for edema and pain.
  d. place the client on bed rest, with the affected leg elevated.

[Alyson.hiatt@yahoo.com]

Answer to Question 1

ANS: B
Trauma to the vaginal area from a forceps birth may result in significant blood loss from hematomas or lacerations. Tachycardia is an early sign of compensation for excessive blood loss. If vital signs suggest hemorrhage but excessive bleeding is not obvious, the cause may be concealed bleeding and the formation of a hematoma; a firm fundus, moderate lochia, and soreness of the perineum are normal findings.

Answer to Question 2

ANS: D
Initial treatment of DVT is bed rest with the leg elevated to decrease swelling and promote venous return. Performing a Homans sign, dorsiflexing the foot, and palpating the leg are contraindicated actions that may dislodge a DVT and result in a pulmonary embolism.

[cartlidgeashley]

Gracias!

[komodo7]

Excellent