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 D
Explanation
Choice a reason:
Temperature monitoring is important in preterm labor to detect infections or inflammations that could complicate the pregnancy. However, while maternal temperature is a vital sign that should be monitored, it is not the priority in this context. The priority is to assess the well-being of the fetus, which is directly indicated by the FHR.
Choice b reason:
Bowel sounds are assessed to ensure gastrointestinal function and to detect potential complications such as ileus or bowel obstruction. In the context of preterm labor, while bowel sounds are part of a comprehensive assessment, they are not the priority over fetal well-being and maternal respiratory status, especially when administering magnesium sulfate, which does not primarily affect gastrointestinal function.
Choice c reason:
Respiratory rate is a critical assessment when administering magnesium sulfate due to the risk of respiratory depression as a side effect of the medication. It is essential to monitor because maternal oxygenation directly affects fetal oxygenation. However, the FHR is a more direct measure of fetal distress and therefore takes priority in this specific assessment.
Choice d reason:
Fetal heart rate (FHR) monitoring is the priority nursing assessment when administering magnesium sulfate IV to a client in preterm labor. Magnesium sulfate can affect uterine contractions and, by extension, fetal oxygenation and well-being. FHR is the most direct indicator of fetal distress, which can occur if the uterus becomes too relaxed and compromises placental blood flow or if there are side effects affecting the mother's cardiovascular status. Therefore, continuous monitoring of FHR is crucial to ensure the fetus is not experiencing distress.
Correct Answer is C
Explanation
Choice A reason:
Precipitous labor is characterized by a labor that progresses rapidly and ends within three hours of its onset. It is not typically associated with painless, bright red vaginal bleeding. This condition is more likely to present with intense, frequent contractions and a rapid change in cervical dilation. Therefore, precipitous labor is not the correct answer in this scenario.
Choice B reason:
Abruptio placentae, also known as placental abruption, is a condition where the placenta detaches from the uterus before delivery. It can cause significant maternal and fetal complications. The classic presentation includes painful bleeding, uterine tenderness, and contractions. Given that the scenario describes painless bleeding, abruptio placentae is less likely to be the correct diagnosis.
Choice C reason:
Placenta previa is a condition where the placenta covers the cervix partially or completely. The hallmark sign of placenta previa is painless, bright red vaginal bleeding, which aligns with the scenario provided. This bleeding can occur spontaneously or be triggered by intercourse or a medical exam. Placenta previa is a serious condition that can lead to maternal and fetal hemorrhage and warrants immediate medical attention. Based on the information provided, placenta previa is the most likely diagnosis for the client described.
Choice D reason:
Threatened abortion refers to vaginal bleeding that occurs in the first 20 weeks of pregnancy, which may indicate a potential miscarriage. Since the client is at 36 weeks gestation, threatened abortion is not a relevant diagnosis for late-term bleeding. Additionally, threatened abortion is often accompanied by abdominal cramping, which is not mentioned in the scenario.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today