A client who delivered vaginally 18-hours ago develops a slight fever. The delivery record shows spontaneous rupture of membranes (SROM) for 36 hours prior to delivery and labor lasting 24 hours. An epidural was placed during labor, and the client experienced a third-degree perineal laceration.
The practical nurse (PN) should recognize which information poses the greatest risk for developing postpartum endometritis?
Epidural anesthesia.
SROM for 36 hours.
Third-degree perineal laceration.
Labor lasting for 24 hours.
The Correct Answer is B
The information that poses the greatest risk for developing postpartum endometritis in this situation is that the client experienced spontaneous rupture of membranes (SROM) for 36 hours prior to delivery. SROM for an extended period of time increases the risk of infection, including postpartum endometritis, which is an infection of the uterus. The practical nurse (PN) should recognize this risk factor and monitor the client closely for signs of infection. The other information listed may also be important to consider, but SROM for 36 hours poses the greatest risk for developing postpartum endometritis in this situation.
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Related Questions
Correct Answer is D
Explanation
The practical nurse (PN) should first massage the fundus and expel retained lochia and clots to help the uterus contract and prevent postpartum hemorrhage.
Taking the vital signs and opening the IV infusion rate of oxytocin (A) may be necessary but not as urgent as massaging the fundus.
Notifying the registered nurse (RN) that the client's bladder is distended (B) is not relevant to addressing the client's boggy and displaced fundus.
Putting the infant to breast to suckle and stimulate oxytocin secretion (C) is a valid intervention, but it is not the first priority when the client's fundus becomes boggy and displaced above the umbilicus.
Correct Answer is B
Explanation
The most important information for the PN to obtain at a health fair for high school students is their immunization history. This information is crucial for ensuring that the students are up-to-date on their vaccinations and protected against preventable diseases.
Option A, obtaining weight and height, is important for assessing overall health and growth but is not the most important information to obtain in this situation.
Option C, checking visual acuity, is also important but not the most crucial information to obtain.
Option D, asking about sexual activity, can provide useful information about the student's sexual health but is not the most important information to obtain in this situation.
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