A nurse is assisting with the care of a client who gave birth 3 days ago.
Complete the diagram by dragging 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 []
- Potential Condition: Endometritis. The symptoms of malaise, chills, decreased appetite, elevated temperature, tachycardia, a boggy and tender uterus, and foul-smelling lochia are indicative of a postpartum infection, such as endometritis.
- Actions to Take:
- Monitor the lochia amount and odor: This will help assess the presence of infection and the effectiveness of treatment.
- Assist with the administration of prescribed antibiotics: Antibiotics are the primary treatment for endometritis.
- Parameters to Monitor:
- Temperature: Monitoring for fever can help assess the response to treatment and indicate if the infection is resolving or worsening.
- Heart rate: Tachycardia may be a sign of infection or other complications, so it's important to monitor changes in heart rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A glucose level of 60 mg/dL is within the normal range for a full-term newborn. Newborns generally have blood glucose levels between 40 and 60 mg/dL in the first few hours of life, and 60 mg/dL is considered acceptable for a 1-day-old newborn.
B. A WBC count of 10,000/mm³ is within the normal range for a newborn. Newborns can have elevated WBC counts due to the stress of birth, and this finding is not immediately concerning.
C. A platelet count of 225,000/mm³ is normal for a full-term newborn. Platelet counts in newborns generally range from 150,000 to 300,000/mm³, so this result falls within the expected range.
D. A hemoglobin level of 9.5 g/dL is low for a 1-day-old newborn. Normal hemoglobin levels for newborns are typically between 14 and 24 g/dL. Low hemoglobin may indicate anemia, which requires further evaluation and management.
Correct Answer is C
Explanation
A. Beginning each feeding with the same breast as the previous feeding is not necessary for effective breastfeeding. It is recommended to allow the newborn to fully drain the first breast before switching to the other side to ensure they receive both foremilk and hindmilk.
B. Newborns do not need additional water. Breast milk or formula provides all the hydration and nutrients a newborn requires, and offering water can interfere with the newborn’s intake of essential nutrients and calories.
C. Allowing the newborn to empty the first breast before switching sides ensures they receive the complete range of milk, including both foremilk and hindmilk, which supports optimal growth and satisfaction.
D. Providing a formula supplement is not typically necessary unless specifically indicated for medical reasons. Exclusive breastfeeding is recommended for the first six months of life, and formula should not be introduced without cause.
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