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A nurse is admitting a client who is to undergo paracentesis for removal of ascitic fluid. Which of the following actions should the nurse take?

A.

Place the client in a side-lying position for the procedure.

B.

Administer a low-volume hypertonic enema the night before the procedure.

C.

Weigh the client before and after the procedure.

D.

Ensure the client has a full bladder just prior to the procedure.

Answer and Explanation

The Correct Answer is C

A. Place the client in a side-lying position for the procedure. Paracentesis is typically performed with the client in a high-Fowler’s or upright position, allowing fluid to collect in the lower abdomen for easier drainage.
B. Administer a low-volume hypertonic enema the night before the procedure. An enema is not required for a paracentesis, as the procedure involves the peritoneal cavity, not the bowel.
C. Weigh the client before and after the procedure. Weighing the client helps assess the amount of fluid removed and monitor for fluid shifts. It is a key part of pre- and post-procedural care to evaluate the effectiveness of the intervention.
D. Ensure the client has a full bladder just prior to the procedure. A full bladder increases the risk of injury during needle insertion. The bladder should be emptied before the procedure to prevent accidental puncture.
 


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Related Questions

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}

Explanation

  • Tocolytic medication: Tocolytics are used to suppress preterm labor, which is not applicable for this postpartum client. There is no indication of uterine contractions needing suppression.
  • Intravenous antibiotic: The client exhibits signs of postpartum endometritis—including fever, uterine tenderness, foul-smelling lochia, and a very high WBC count (33,000/mm³). These findings strongly support the need for IV antibiotics to treat the infection.
  • Intrauterine tamponade balloon: This device is used for managing postpartum hemorrhage, which is not present in this case. The client’s lochia is moderate, not excessive, and her uterus is responding to massage.
  • Kleihauer-Betke test: This test is used to detect fetal-to-maternal hemorrhage, particularly in Rh-negative mothers after trauma or potential placental separation. It is not relevant in the context of postpartum infection.
  • Increase in daily fluid intake: The client is febrile and shows signs of systemic infection. Increased fluids support hydration, promote recovery, and help manage the effects of fever and infection, making this an appropriate supportive measure.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A","dropdown-group-3":"C"}

Explanation

  • Endometritis – This uterine infection is one of the most common postpartum complications, especially following cesarean delivery and prolonged rupture of membranes. It often presents with foul-smelling lochia, uterine tenderness, and systemic signs of infection like fever and leukocytosis. This client’s presentation, including foul-smelling lochia and a WBC of 33,000/mm³, strongly supports this diagnosis.
  • Mastitis – Typically associated with localized breast pain, redness, swelling, and systemic symptoms like fever. While the client has nipple discomfort and firm breasts, these are common postpartum findings during milk let-down and do not meet the criteria for mastitis, especially without signs of inflammation or localized breast infection.
  • Pulmonary embolism – A PE generally presents with sudden-onset chest pain, dyspnea, tachypnea, and hypoxia. This client’s oxygen saturation is normal, lung sounds are clear, and there is no respiratory distress, making PE unlikely.
  • Postpartum hemorrhage – Hemorrhage would present with excessive vaginal bleeding, hypotension, tachycardia, and possibly uterine atony. This client’s uterus is firm, lochia is moderate (not heavy), and vital signs are stable, so hemorrhage is not supported by the data.
  • Lochia assessment – Foul-smelling lochia is a classic indicator of uterine infection. It points to endometritis when found with other risk factors like cesarean birth, prolonged labor, and signs of systemic inflammation.
  • Elevated white blood cell count – A postpartum WBC count may be mildly elevated, but a level of 33,000/mm³ suggests infection. When combined with clinical symptoms like uterine tenderness and malodorous discharge, it supports a diagnosis of endometritis.
  • Firm uterus at 1 cm above umbilicus – This finding is expected on postpartum day 3 and indicates normal uterine involution. A firm uterus rules out uterine atony and is not specific to infection or hemorrhage.
  • Moderate nipple discomfort – Breast fullness and nipple tenderness are common in breastfeeding mothers, especially in the early postpartum period. This discomfort alone does not indicate mastitis or any systemic infection.

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