A nurse is assessing a client who is 6 hours postpartum and has endometritis. Which of the following findings should the nurse expect?

Temperature 37.4°C (99.3°F)

Scant lochia

Uterine tenderness

WBC count 9,000/mm³

Answer and Explanation

The Correct Answer is C

Endometritis is an infection of the endometrium, the lining of the uterus, typically occurring after childbirth. When assessing a client with endometritis, the nurse should expect to find uterine tenderness as a common clinical finding. This finding is consistent with endometritis, which is characterized by inﬂammation and infection of the endometrium. Additional signs and symptoms may include an elevated temperature, increased lochia, foul-smelling lochia, and an elevated WBC count. Prompt identification and treatment of endometritis are important to prevent further complications.

Option a) A temperature of 37.4°C (99.3°F) is within the normal range and does not necessarily indicate endometritis. However, an elevated temperature above 38°C (100.4°F) or a persistent fever may be indicative of an infection and should be further evaluated.

Option b) Scant lochia (minimal vaginal bleeding) is not a characteristic finding of endometritis. In endometritis, lochia is often increased in amount and may have an unpleasant odor.

Option d) A white blood cell (WBC) count of 9,000/mm³ is within the normal range. However, in cases of endometritis, there is usually an elevation in the WBC count as a response to the infection. An elevated or increasing WBC count may be observed.

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Correct Answer is A

Explanation

A spontaneous abortion (also called a miscarriage) is the unexpected ending of a pregnancy in the first 20 weeks of gestation. The major symptoms of a spontaneous abortion are abdominal cramps and bleeding from the vagina, sometimes with clots and/or bits of tissue³. A dilated cervix indicates that abortion is inevitable¹. Other symptoms may include low back ache, a decrease in pregnancy symptoms, and leaking amniotic ﬂuid.

The other options are not answers because they are not indicative of an imminent spontaneous abortion.

b. Slight abdominal cramps

Slight abdominal cramps are a common symptom of early pregnancy and do not necessarily mean that a miscarriage is happening. However, if the cramps are severe, persistent, or accompanied by bleeding, then they could be a sign of a problem and should be reported to the provider.

c. Elevated hCG

hCG (human chorionic gonadotropin) is a hormone produced by the placenta during pregnancy. It can be measured in the blood or urine to confirm pregnancy or monitor its progress. Elevated hCG levels are not a sign of a spontaneous abortion, but rather a normal finding in early pregnancy. In fact, low or decreasing hCG levels may indicate a miscarriage or an ectopic pregnancy.

d. Scant bright red spotting

Scant bright red spotting is another common symptom of early pregnancy and does not necessarily mean that a miscarriage is happening. It may be caused by implantation bleeding, cervical irritation, or sexual intercourse. However, if the spotting is heavy, dark, or accompanied by cramps or pain, then it could be a sign of a problem and should be reported to the provider.

A. Keep the newborn supine throughout treatment. B. Dress the newborn in lightweight clothing. C. Measure the newborn's temperature every 8 hours. D. Avoid using lotion or ointment on the newborn's skin.

Correct Answer is D

Explanation

Phototherapy is a treatment that uses light to lower the level of bilirubin in the blood of newborns who have jaundice. Jaundice is a condition that causes yellowing of the skin and eyes due to high levels of bilirubin, a waste product that is normally removed by the liver. Phototherapy helps the body break down and eliminate bilirubin through urine and stool¹.
Phototherapy can be done at home or in the hospital, depending on the severity of jaundice and the type of light used. The most common types of light are ﬂuorescent lamps, halogen lamps, or light-emitting diodes (LEDs). The light can be delivered through overhead units, fiber-optic blankets, or fiber-optic pads. The light should cover as much of the newborn's skin as possible, except for the eyes and genitals¹².

The nurse should follow certain guidelines when caring for a newborn who is receiving phototherapy, such
as:
- Monitor the newborn's temperature, hydration, weight, and urine and stool output regularly
- Protect the newborn's eyes with eye patches or goggles to prevent eye damage
- Turn the newborn every 2 to 4 hours to expose diﬀerent parts of the body to the light
- Feed the newborn frequently to prevent dehydration and promote bilirubin excretion

- Check the newborn's skin color and bilirubin level periodically to evaluate the eﬀectiveness of
phototherapy
- Provide emotional support and education to the parents about jaundice and phototherapy
One of the important guidelines is to avoid using lotion or ointment on the newborn's skin during phototherapy. This is because lotion or ointment can block the light from reaching the skin and reduce the eﬀectiveness of phototherapy. Lotion or ointment can also cause skin irritation, rash, or burns if they react with the light. The newborn's skin should be clean and dry before phototherapy¹²³.

The other options are not actions that the nurse should include in the plan of care:
- a) Keep the newborn supine throughout treatment. This is not correct because keeping the newborn in one position can limit the exposure of diﬀerent parts of the body to the light and reduce the eﬀectiveness of phototherapy. The nurse should turn the newborn every 2 to 4 hours to expose diﬀerent parts of the body to the light¹².
- b) Dress the newborn in lightweight clothing. This is not correct because dressing the newborn in clothing can block the light from reaching the skin and reduce the eﬀectiveness of phototherapy. The newborn should be undressed except for a diaper during phototherapy¹².
- c) Measure the newborn's temperature every 8 hours. This is not correct because measuring the newborn's temperature every 8 hours may not be frequent enough to detect any changes in temperature that may occur during phototherapy. Phototherapy can cause overheating or hypothermia in newborns, depending on the type and intensity of light used. The nurse should monitor the newborn's temperature more often, such as every 2 to 4 hours, and adjust the room temperature or use blankets as needed¹².

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A nurse is assessing a client who is 6 hours postpartum and has endometritis. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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