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Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

A client is 48 hours postpartum following a primary cesarean birth. The practical nurse is assisting with data collection prior to the client's planned discharge. Which finding is the highest priority to report to the registered nurse?

  1. A
    Lochia serosa consisting of a scant amount of pinkish-brown drainage
  2. B
    Reports of mild, intermittent abdominal cramping during newborn breastfeeding
  3. Unilateral calf swelling accompanied by localized redness and warmthAnswer
  4. D
    An oral temperature of 99.4°F (37.4°C) after a short walk in the hallway

Answer

Unilateral calf swelling accompanied by localized redness and warmth
Pregnancy and the postpartum period are hypercoagulable states, and a cesarean birth further increases the risk for deep vein thrombosis (DVT). Unilateral calf swelling, redness, and warmth are classic clinical indicators of a DVT. Because a DVT can dislodge and cause a life-threatening pulmonary embolism (a circulatory emergency), this finding is the highest priority and must be reported to the registered nurse immediately.

Step-by-Step Solution

1
Analyze the client's timeframe and surgical history.
The client is 48 hours postpartum after a cesarean birth, placing her at an increased physiological risk for hypercoagulability and thromboembolic events.
Pregnancy and surgery both increase the risk of deep vein thrombosis (DVT).
2
Evaluate the clinical data in each option to distinguish normal adaptations from complications.
Pinkish lochia, mild cramping during breastfeeding, and a low-grade temperature are all expected physiological findings at this stage.
Recognizing normal postpartum healing prevents unnecessary alarm and allows the nurse to focus on true abnormalities.
3
Identify the finding that represents a threat to life or safety (ABC prioritization).
Unilateral calf swelling with redness and warmth is a sign of a circulatory complication (DVT) that could lead to a pulmonary embolism.
Circulatory emergencies take priority over expected normal findings and expected procedural pain.

Key Concept

Postpartum Complications: Recognizing Deep Vein Thrombosis (DVT)
Estimated Time:1m 0s
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Topics

Ante/Intra/Postpartum and Newborn Care

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