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
Elevating the client's legs is incorrect as an initial intervention. It is more important to address the potential cause of the late decelerations first.
Choice B rationale
Turning the client onto their side is correct. This intervention can improve blood flow to the fetus and reduce the pressure on the vena cava, potentially alleviating late decelerations.
Choice C rationale
Palpating the client's uterus is not the first action. It is essential to address maternal positioning and oxygenation issues first.
Choice D rationale
Increasing the client's IV fluid infusion rate may help, but it is not the initial action. Positioning changes can have an immediate effect on fetal oxygenation.
Correct Answer is B
Explanation
Choice A rationale
Using a disposable razor for shaving while taking warfarin can increase the risk of cuts and bleeding, which should be avoided due to the anticoagulant effects of warfarin.
Choice B rationale
Oral contraceptives should not be taken while on warfarin because they can increase the risk of blood clots, counteracting the effect of the anticoagulant.
Choice C rationale
Stopping warfarin in 2 weeks is incorrect advice, as the duration of therapy varies depending on the condition being treated and the individual's response to the medication.
Choice D rationale
Taking 650 milligrams of aspirin for leg discomfort is not advised while on warfarin, as aspirin can increase the risk of bleeding by affecting platelet function and the blood clotting process.
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