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. Insert the suppository 5 cm (2 in) is incorrect. The suppository should be inserted about 2-3 inches into the vaginal canal, not specifically 5 cm, but the exact depth may vary.
B. Insert the suppository along the posterior vaginal wall is correct. Inserting the suppository along the posterior vaginal wall helps ensure it reaches the area where it is needed for effective treatment.
C. Apply petroleum jelly to the suppository is incorrect. The suppository should not be coated with petroleum jelly; it should be used as is to avoid interference with its absorption and effectiveness.
D. Assist the client into a prone position is incorrect. The client should be assisted into a supine position with knees bent or into a lithotomy position for the insertion of the suppository, not a prone position.
Correct Answer is B
Explanation
A. Pruritus is not a common manifestation of hyperemesis gravidarum; it might be associated with liver conditions or other issues.
B. Decreased blood pressure can be an expected manifestation in hyperemesis gravidarum due to dehydration and possible hypovolemia.
C. Hemoglobin of 18 g/dL is higher than normal; hyperemesis gravidarum often leads to decreased hemoglobin due to malnutrition and dehydration.
D. A WBC count of 15,000/mm³ is slightly elevated but not specific for hyperemesis gravidarum; it might be indicative of an infection or inflammation, but it is not a defining characteristic of the condition.
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