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.

Answer and Explanation

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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Correct Answer is D

Explanation

If a postpartum client who delivered vaginally 6-hours ago and had a second-degree perineal laceration reports feeling increased pain and pressure in her vaginal area, the practical nurse (PN) should apply an icepack to the perineum.Applying an icepack can help reduce swelling and provide pain relief in the aﬀected area. The PN should also monitor the client's condition and report any changes or concerns to the healthcare provider. The other interventions listed may also be appropriate in some situations, but applying an icepack to the perineum is the most appropriate initial intervention in this situation.

A. Encourage the client to be calm and relax for a little while. B. Allow time for the behavior and then redirect the client to other activities. C. Teach the client thought-stopping techniques and ways to refocus behaviors. D. Assist the client to identify stimuli that precipitate the activity.

Correct Answer is B

Explanation

This is the most appropriate intervention for the PN to implement when approaching a client who is exhibiting compulsive behavior. By allowing time for the behavior, the PN acknowledges the client's need to perform the behavior and avoids creating further stress for the client. Redirecting the client to other activities can also help to refocus the client's behavior and prevent further compulsive behavior.

Encouraging the client to be calm and relax for a little while (A) may not be eﬀective in managing the compulsive behavior.

Teaching the client thought-stopping techniques and ways to refocus behaviors (C) and assisting the client to identify stimuli that precipitate the activity (D) are interventions that may be used in the long term, but they may not be immediately eﬀective in managing the client's behavior in the moment.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A postpartum client who delivered vaginally 6-hours ago and had a second-degree perineal laceration reports feeling increased pain and pressure in her vaginal area. Which intervention should the practical nurse (PN) implement?

Correct Answer is D

Explanation

During morning rounds, a client who is admitted with obsessive-compulsive disorder is in the dayroom repeatedly washing the top of the same table. Which intervention should the practical nurse (PN) implement when approaching the client?

Correct Answer is B

Explanation

The practical nurse (PN) is caring for a newborn whose mother has poorly controlled type 1 diabetes mellitus and observes the newborn is grunting with mild sternal retractions. The PN should recognize the newborn is exhibiting signs of which condition?

The practical nurse (PN) caring for a 3-month-old boy one day after a pyloromyotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the PN take?

Another person tells the practical nurse (PN) that her 7-year-old child frequently wets the bed at night. Which information should the PN provide?

A 3-week-old infant is admited to the pediatric unit with vomiting and dehydration. The mother describes the infant as having projectile vomiting after eating. She also tells the practical nurse (PN) that the baby is always hungry. Which finding warrants immediate intervention by the PN?

The practical nurse (PN) is caring for a 3-month-old infant with a head injury who had a seizure episode. The infant has a high-pitched cry and is irritable. The caregiver reports that the infant rolled over and fell onto the carpeted ﬂoor. Which action should the PN take?

The client tells the practical nurse (PN), "I have been applying triple antibiotic ointment to my athlete's foot for the past two days, but it still itches. How should the PN respond?