Which of the following findings should lead the nurse to suspect that a client who had a cesarean delivery 8 hours earlier is developing disseminated intravascular coagulation (DIC) and report to the health care provider? Select all that apply.
1. Petechiae on the arm where the blood pressure was taken.
2. Heart rate of 126 bpm.
3. Abdominal incision dressing with bright red drainage.
4. Platelet count of 80,000/mm3.
5. Urine output of 350 mL in the past 8 hours.
6. Temperature of 98.4°F (36.9°C).
DIC is diagnosed based on clinical symptoms and laboratory findings. Findings such as excessive and unusual bruising or bleeding over areas of tissue trauma, such as IV insertion or incision sites or application of a blood pressure cuff should be reported to the health care provider.
Tachycardia and diaphoresis also may be noted. Laboratory results reveal low platelet, fibrinogen, proaccelerin, antihemophiliac factor, and prothrombin levels. Bleeding time is normal and partial thromboplastin time is increased. A urine output of 350 mL in 8 hours indicates adequate renal function. Temperature is not an indication of DIC.
CN: Physiological adaptation; CL: Analyze.
Answer:1, 2, 3, 4.
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