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A nurse is assessing a client who has endometritis. Which of the following findings should the nurse expect?

A.

Temperature 37.7° C (99.9° F)

B.

Polyuria

C.

Malodorous lochia

D.

Heart rate 56/min

Answer and Explanation

The Correct Answer is C

Rationale:

A. Temperature 37.7° C (99.9° F): This temperature is only slightly elevated and not strongly indicative of infection. Endometritis typically presents with a fever above 38°C (100.4°F), reflecting a more pronounced inflammatory response.

B. Polyuria: Increased urine output is not a characteristic sign of endometritis. It may be seen with conditions such as diabetes mellitus or post-diuresis but is unrelated to uterine infection.

C. Malodorous lochia: Foul-smelling lochia is a key clinical sign of endometritis, indicating infection of the uterine lining. It often accompanies uterine tenderness, fever, and possibly abdominal pain.

D. Heart rate 56/min: Bradycardia is not typical in endometritis. Instead, clients may present with tachycardia as part of the systemic inflammatory response to infection. A low heart rate would be unexpected.


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Related Questions

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A,B"}}

Explanation

Rationale:

  • Excessive spending habits: This behavior is hallmark for mania, where impaired judgment, impulsivity, and inflated self-esteem lead to reckless financial decisions.
  • Hallucinations: Hallucinations, especially visual or auditory ones, are classic signs of psychosis. They indicate a break from reality and are not a diagnostic feature of mania alone unless psychotic features are present.
  • Pressured speech: Pressured, rapid, and loud speech is a diagnostic feature of mania, reflecting heightened psychomotor activity and racing thoughts.
  • Lack of sleep: Insomnia without fatigue is typical in mania. Clients may stay awake for days with increased energy levels and no perceived need for rest.
  • Disorganized thought process: This can appear in both mania and psychosis. In mania, it stems from flight of ideas and distractibility. In psychosis, it results from impaired reality testing and cognitive disintegration.

Correct Answer is D

Explanation

Rationale:

A. Insert the oral thermometer in front of the infant's tongue: Oral temperature measurement is not appropriate for infants due to the risk of injury and their inability to hold the thermometer properly. It is generally reserved for children older than 4–5 years.

B. Pull the pinna of the infant's ear forward before inserting the probe: When using a tympanic thermometer for infants under 3 years, the correct method is to pull the pinna down and back, not forward, to straighten the ear canal.

C. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: This depth is too invasive and risks rectal perforation. For infants, rectal insertion should be only 1.5 to 2.5 cm (0.6–1 in), with extreme caution.

D. Place the tip of the thermometer under the center of the infant's axilla: Axillary temperature is the safest and most noninvasive route for infants. Ensuring full skin contact under the center of the axilla provides the most accurate axillary reading.

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