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 B
Explanation
A. The urinary catheter is usually removed within the first 24 hours after a cesarean birth, not 48 hours. Early removal helps prevent complications and promotes recovery.
B. Uterine massage is performed to prevent postpartum hemorrhage and ensure the uterus is contracting properly. This practice is part of standard postpartum care to promote uterine involution.
C. Postoperative diet progression typically starts with clear liquids and advances as tolerated. Regular food is introduced once the client can swallow safely and shows no signs of nausea or gastrointestinal issues.
D. Staying flat on the back is not required post-cesarean section. Early ambulation is encouraged to prevent complications like deep vein thrombosis and to promote healing.
Correct Answer is D
Explanation
A. Leukorrhea, a normal increase in vaginal discharge, is a common and expected finding during pregnancy. It usually does not require immediate medical intervention unless accompanied by other symptoms.
B. Gingivitis is a common issue during pregnancy due to hormonal changes, but it is generally managed with good oral hygiene and routine dental care. It is not an urgent finding compared to other conditions.
C. Varicose veins are a common condition during pregnancy due to increased blood volume and pressure on the veins. While they can be uncomfortable, they are generally managed through lifestyle changes and do not represent an immediate risk.
D. Dysuria, or painful urination, may indicate a urinary tract infection or another serious condition that requires prompt medical attention. It can lead to complications if untreated, so it is a priority finding that needs to be reported to the provider for further evaluation and treatment.
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