A nurse is assessing a client for postpartum infection. Which of the following findings should indicate to the nurse that the client requires further evaluation for endometritis?
Pelvic pain
Hematuria
A localized area of breast tenderness
A moderate amount of dark red lochia with a foul odor
The Correct Answer is A
Choice a) reason: Pelvic pain is a common symptom of endometritis. The pain is typically located in the lower abdomen and may be associated with uterine tenderness upon physical examination. This symptom, especially when combined with other signs such as fever and foul-smelling lochia, strongly suggests the need for further evaluation for endometritis.
Choice b) reason: Hematuria, or blood in the urine, is not a typical symptom of endometritis. While it could be a sign of other postpartum complications, such as urinary tract infections or bladder injury during childbirth, it does not directly indicate endometritis.
Choice c) reason: A localized area of breast tenderness is more indicative of a breast infection, such as mastitis, especially if associated with breastfeeding. It is not a symptom of endometritis, which affects the uterus and not the breasts.
Choice d) reason: While foul-smelling lochia can be a sign of endometritis, the key is the presence of a foul odor. A moderate amount of dark red lochia alone, without a foul odor, is a normal finding in the immediate postpartum period. It's the transition from rubra (red) to serosa (pink/brown) to alba (yellow/white) that is expected as the uterus heals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
The recommended intake of iron does not necessarily increase during lactation. In fact, the iron requirement may decrease because menstruation usually ceases, reducing iron loss. However, maintaining adequate iron intake is still important for overall health and to support the baby's growth.
Choice B Reason:
Zinc is crucial for immune function, cell division, and growth, making it an important nutrient during lactation. The recommended dietary allowance (RDA) for zinc for lactating women is indeed higher than for non-pregnant, non-lactating women, with an RDA of about 12 mg per day.
Choice C Reason:
While calcium is important for bone health, the recommended intake for lactating women is not as high as 2,000 mg per day. The RDA for calcium for lactating women is about 1,000 mg per day, similar to that for non-lactating women.
Choice D Reason:
The recommended intake of folic acid does not remain the same as for pregnant women. During pregnancy, the RDA for folic acid is higher to prevent neural tube defects. While folic acid is still important during lactation for cell growth and DNA synthesis, the requirement is slightly lower than during pregnancy.
Correct Answer is D
Explanation
Choice A reason:
Nausea can be a common side effect of many medications and does not necessarily indicate toxicity. While it can be uncomfortable for the patient, nausea alone, without other symptoms, is not typically a sign of magnesium sulfate toxicity.
Choice B reason:
Drowsiness is another side effect that can occur with various medications and medical conditions. It may be a symptom of magnesium sulfate toxicity, especially if it is severe or combined with other symptoms, but on its own, it is not a definitive indicator of toxicity.
Choice C reason:
Facial flushing can be a reaction to medication, including magnesium sulfate, and may occur even at therapeutic levels. It is not usually a sign of toxicity unless accompanied by more serious symptoms.
Choice D reason:
Respiratory depression is a serious and potentially life-threatening condition that can indicate magnesium sulfate toxicity. It is characterized by a decrease in the ability to breathe and a drop in oxygen levels. This is a critical finding that requires immediate medical attention and intervention.
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