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
The correct answer is choice d. “The nurse should measure the newborn’s muscle tone when assigning an Apgar score.”
Choice A rationale:
The Apgar score is determined at 1 and 5 minutes after birth, not at 2 and 7 minutes.
Choice B rationale:
An Apgar score of 8 indicates that the newborn is in good health, not severe distress. Scores of 7-10 are considered normal.
Choice C rationale:
Resuscitation efforts should not be delayed until the first Apgar score is obtained. Immediate resuscitation is initiated if needed, regardless of the Apgar score.
Choice D rationale:
Muscle tone is one of the five criteria assessed in the Apgar score, along with appearance, pulse, grimace, and respiration.
Correct Answer is ["B","C"]
Explanation
Choice A rationale:
Newborn weight of 2.948 kg (6 lb 8 oz) does not place the client at risk for postpartum hemorrhage. Newborn weight is not directly related to the risk of postpartum hemorrhage in the mother.
Choice B rationale:
History of uterine atony places the client at risk for postpartum hemorrhage. Uterine atony is the most common cause of postpartum hemorrhage and refers to the inability of the uterus to contract effectively after childbirth, leading to excessive bleeding.
Choice C rationale:
Labor induction with oxytocin places the client at risk for postpartum hemorrhage. Oxytocin is commonly used to induce labor or augment contractions, but it can cause uterine hyperstimulation, leading to increased risk of postpartum hemorrhage.
Choice D rationale:
History of human papillomavirus (HPV) does not place the client at risk for postpartum hemorrhage. HPV is a sexually transmitted infection and does not have a direct connection to the risk of postpartum hemorrhage.
Choice E rationale:
Vacuum-assisted delivery places the client at risk for postpartum hemorrhage. Vacuum assisted delivery involves using a vacuum device to assist in the baby's delivery, and it can cause trauma to the birth canal, leading to increased bleeding risk in the mother.
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