A nurse is assisting with the care of a 28-year-old female client who gave birth 3 days ago in the maternal newborn unit.
Complete the diagram by selecting from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Endometritis is indicated by a high temperature (38.4°C), elevated heart rate (108/min), foul-smelling lochia, and a tender boggy uterus. These are classic signs of infection post-cesarean birth, particularly following prolonged rupture of membranes, which increases infection risk. Administering broad-spectrum antibiotics targets the infection, while oxytocic medication helps manage uterine atony and promote uterine contraction to expel infected lochia.
Actions Explanation:
- Administer broad-spectrum antibiotic medication: This addresses the underlying infection causing endometritis.
- Monitor the administration of an oxytocic medication: Ensures uterine contraction, reducing uterine atony and helping clear infected materials.
Parameters to Monitor:
- Temperature: Indicates the presence and resolution of infection.
- Lochia amount and odor: Helps assess the severity of infection and effectiveness of treatment.
Other Conditions:
- B. Urinary tract infection (UTI): Less likely since the client denies urinary symptoms like burning or difficulty.
- C. Deep vein thrombosis (DVT): Bilateral lower extremity edema without pain, warmth, or tenderness doesn't align with unilateral swelling/pain typical of DVT.
- D. Engorgement: Not likely since the client is bottle-feeding and denies nipple discomfort; also, the lochia characteristics and boggy uterus point to infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
1/2 cup (4 oz) orange juice provides about 55 micrograms of folate. While it is a good source of vitamin C and other nutrients, it does not contain as much folate compared to leafy greens.
Choice B rationale
1 cup cooked spinach contains approximately 263 micrograms of folate, making it one of the richest sources of this essential vitamin. Folate is crucial for DNA synthesis and cell division, especially during pregnancy.
Choice C rationale
1 large egg contains about 24 micrograms of folate. Although eggs offer several nutrients like protein and vitamins, their folate content is relatively low compared to green vegetables.
Choice D rationale
1 cup pasta has around 102 micrograms of folate, assuming it is enriched pasta. While it contributes to daily folate intake, it does not compare to the high levels found in spinach.
Correct Answer is E,A,C,D,B
Explanation
- Wrap a warm, moist cloth around the heel.
- Cleanse the heel with an antiseptic.
- Puncture the heel and collect the blood.
- Apply pressure with a dry gauze pad.
- Cover the heel with an adhesive bandage. .
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