A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?
Temperature 37.4°C (99.3°F).
Uterine tenderness.
WBC Count 9,000/mm.
Scant lochia.
The Correct Answer is B
Choice A rationale:
A postpartum temperature of 37.4°C (99.3°F) is within the normal range. Mild temperature elevations can be expected in the immediate postpartum period without indicating infection.
Choice B rationale:
Uterine tenderness is a common finding in endometritis, which is an inflammation or infection of the inner lining of the uterus. The condition can cause pelvic pain and uterine tenderness.
Choice C rationale:
A white blood cell (WBC) count of 9,000/mm³ falls within the normal range for a postpartum client. In endometritis, an elevated WBC count would be expected due to the infection.
Choice D rationale:
Scant lochia (minimal vaginal discharge after childbirth) is a normal finding in the postpartum period and is not associated with endometritis. In endometritis, the lochia may be increased and foul-smelling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
This statement is incorrect. An indirect Coombs' test is not used to determine the risk of hypoglycemia in a baby after birth. It is used to detect antibodies against red blood cells, particularly in the context of blood incompatibility between a pregnant woman and her fetus.
Choice B rationale:
This statement is incorrect. An indirect Coombs' test is not related to determining the amount of amniotic fluid around the fetus. It is used primarily to assess for Rh incompatibility between the mother and fetus.
Choice C rationale:
This statement is incorrect. The test described here is a Doppler ultrasound, not an indirect Coombs' test. Doppler ultrasound is used to study blood flow in the fetus and placenta using ultrasound waves.
Correct Answer is C
Explanation
The correct answer is choice c. One acceleration of the FHR within a 20-min period.
Here's the rationale for each choice:
Choice A: Rationale: A non-stress test (NST) is supposed to assess fetal well-being by looking for accelerations in the fetal heart rate (FHR) in response to fetal movement. An FHR that peaks 20 beats above the baseline is a desirable finding in an NST, indicating good fetal reactivity.
Choice B: Rationale: While not typical during a standard NST, three uterine contractions within a 20-minute period might not necessarily require immediate intervention. However, the nurse should document it and notify the healthcare provider for further assessment, especially if the contractions are causing discomfort or if there are other concerning signs.
Choice C: Rationale: A single acceleration of the FHR within a 20-minute NST is considered non-reactive and may indicate fetal compromise. This finding requires further investigation by the healthcare provider, potentially including additional monitoring or interventions.
Choice D: Rationale: Uterine contractions lasting 20 to 30 seconds each are not a typical finding during an NST, but they may not necessarily be a cause for immediate concern unless they are causing the client pain or are accompanied by other concerning signs. The nurse should document the contractions and notify the healthcare provider.
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